I’m not sure if it was ever any different, but it is certainly no longer possible to study bioethics in isolation. This book would not have been possible without the input of many people who have generously shared their knowledge and experience with me. Thank you all.

This book was greatly enhanced by the generosity of a grant from The Center for Bioethics and Human Dignity at Trinity International University in Deerfield, Illinois, USA, through their Global Bioethics Education Initiative. I would also like to thank the ‘Free Money for New Lives’ campaign, which contributed a substantial sum to this project.

I have been humbled by the graciousness I have been shown during the five years I have worked to put this book together. I have spoken to countless people who have lived through the challenges discussed within these pages, and I am deeply indebted to them all for sharing part of their lives with me. Many experts have kindly answered my questions as I have studied the current practice of medicine at the beginning of life, and the associated theology. I appreciate the assistance given by Andrew Cameron, Don Carson and my research assistant Elizabeth Hegedus. Thank you Andrew and Penny Wilkinson for your hospitality. A particularly big thank you to those who gave the time to read through chapters at draft stage and make suggestions: Kirsten Birkett, Peter Bland, Patrina Caldwell, Anne and Geoff Campbell, Patricia Chan, Sam Chan, Sarah Condie, Angela Ferguson, Andrew Ford, Peter Jensen, David Kardachi, Jonathon Morris, Kirk and Lisa Patson, Jeff Persson, Karin Sowada, Rob Smith, Joseph Thomas Thenalil and Ron Vaughan. Some of those chapters were really long. All remaining errors are my own.

To the staff at Matthias Media, a big thank you for all your work in putting the book together, especially my editors Tony Payne, Lee Carter and Emma Thornett, and to Hayley Boag who had to bear with my late additions. The book would not have been what it is without your long hours of labour.

Finally, a big thank you to my family, who have put up with me being distracted by all things embryonic for such a long time—to Amoni and Susannah, who bring me so much joy, and finally to my husband, John, without whose care, support and cups of tea this book would never have been written. In acknowledgement of his invaluable contribution I dedicate this book to him.


I read a newspaper article the other day, with this headline:

‘Are these babies really a crime?’

Underneath were photographs of two adorable children lovingly clasped in their parents’ arms. It was a story about gestational surrogacy, prompted by the birth of children to high-profile parents through the use of a surrogate mother.

Are they a crime? Of course not. All babies are beautiful, and these children are loved by their families and no doubt bring much joy. But it highlights the difficulty in evaluating the morality of issues in reproduction, because reproductive technologies are aiming to provide things that are in themselves good—things that are normal for humans to desire; things that we all desire. Because these technologies aim to satisfy these good desires, we hesitate to brand them as wrong. Nonetheless, evaluating them objectively is a necessary task if we are to put all areas of our lives under the lordship of Jesus Christ.

I have written this book in response to many requests from Christians who are struggling to find the information they need to think clearly about the morality of reproductive technology. I write from the perspective of believing that human life begins at fertilization and deserves protection from that time. I will give my reasons for this position, but I accept that some will not agree with me. This book may not be for them (although I hope and trust that it will provide clear and useful information on the current state of play in medicine and technology for all readers). The book will be particularly relevant to those who hold the Christian Bible as authoritative, and want to see how it can be applied to modern reproductive dilemmas.

These matters involve personal decisions for which we will answer to God alone. No blame is intended for those whose past choices are now regretted. We make the best decisions we can with the information we have at the time. I now know from experience how difficult it is to get accurate information on some of these topics. This information is intended to help us look forward, not back, and make the best choices we can in the future. We live in a fallen world and none of us is free from the ravages of sin. Thank God that he knows our hearts and forgives our sins when we confess them to him (as 1 John 1:9 promises). Finally, I realize that some of the subject matter in this book refers to unspeakable personal suffering. May the God of all comfort hold you in the palm of his hand.

Megan Best

July 2012

The dilemma

Is it ever right to have an abortion? What about the case of a young girl who has been raped? Or what if the baby has something seriously wrong with it and we know it can’t survive?

What about the right to have a child? When we ‘create’ test-tube babies, are we saying we know better than God who should be a parent? Is IVF ever okay for Christians?

These are all very good questions. However, they are also difficult questions that affect the whole of our lives. Children are a blessing from the Lord, and it is right and good to desire them. Yet the technology that can make fertility control possible does not always operate within a framework where human beings are valued from the time they are created. Not only that, but as more and more extreme manipulations of unborn humans become available, the less extreme ones seem more reasonable by comparison. Before we know it, as a community we find ourselves regarding unborn human life as a resource to use rather than a gift to cherish. We contemplate our ethical dilemmas and say to ourselves, ‘How did we end up here?’

Due to the development of reliable contraception and assisted reproductive technologies (ART) we are told that we can now have sex without children, and children without sex. The question is: should we? The urge to have a baby can be powerful, and the fear of an unplanned pregnancy can be overwhelming. Faced with unmet desires in a world where anything seems technologically possible, in a climate where we are used to being in control, the pull between what is possible and what is ethical can create an unbearable tension.

People in church circles often feel this tension strongly, but discussions about practical issues arising from our sexuality can be awkward and embarrassing, involving as they do images of “glistening eyes and soft dark orifices, moisture and menses, muscle and bones and blood”.[1] However, God made us as embodied creatures, and our physicality is an important part of what it means to be human. As the way society views our bodies moves further and further from the biblical understanding, we need to think through a truly Christian understanding of human procreation.

Reformed Christianity has not always been strong in this area. In fact, it is difficult to find a comprehensive theology of the issues surrounding human procreation. Whatever the reasons in the past, as the science involved gets more complex, it is imperative that we get a clear theologically driven handle on the questions it raises. Recent controversies about the morality of research on human embryos have made many people think more carefully about other ways we treat humans in this early stage of development. I am regularly asked, “If it’s not okay to kill a human embryo for research, why aren’t we more careful to check which contraceptives do the same thing?”

This book, then, is an attempt to examine the different aspects of the quest for married couples to plan their families. It is not intended to replace a medical consultation at any level, but to give information that allows the reader to prepare ahead, and to think through the issues from a biblical point of view.

As we do so, there will be some inevitable clashes with the prevailing views of our society. Sometimes we will need to go against the flow, and not fall in with accepted modern practices. We will examine things carefully, and if necessary, do things differently, in order to be faithful to God. This can be hard. You might be seen as a nuisance or a crackpot. But Jesus Christ has called us to be salt and light in the corruption of our generation. We are the people of God. We should look different, and when we live out the kingdom’s values we bring glory to God.

Modern reproductive technology is very complex, and it is difficult to make ethical judgements about reproductive therapies if we don’t understand what is actually being done. This book is therefore organized to help you understand those areas with which you may be unfamiliar. As you read, please remember that this is an international publication, and so the availability of some practices will vary in different countries.

Many of the key topics in medical ethics revolve around the question of when human life begins, so it is important we clarify that issue at the outset. We start by considering the biology of how human life develops in the womb, before looking in chapter 3 at the philosophical and theological questions of when life begins. Human beings are made for relationships, and we cannot make important life decisions in any other context, so chapter 4 looks at the background of biblical teaching on human relationships. A model for ethical Christian decision-making is offered in chapter 5 so that we can determine a biblical way to decide right from wrong, and see how this will differ from others in our community.

Following that we will consider separately the areas that can hold ethical problems for those who believe life begins at fertilization. This book assumes that the place for sexual relationships for Christians is within marriage. At the beginning of our married lives, there is usually more interest in contraception than child-bearing, so we begin with that topic in chapter 6. The easily available option of reversible contraceptives has, however, reduced the tolerance for unplanned pregnancy, so the corollary of legal abortion was almost inevitable. We deal with it next in chapter 7.

We look at normal pregnancy and find out the new and sinister agendas underlying many modern practices in chapter 8. In chapter 9we go on to consider what can be done when you discover there is something wrong with your longed-for child.

Of course, not all couples will be able to have the baby they wish for, so in chapter 10 we examine infertility, before touching on the silent sorrow of miscarriage and stillbirth in chapter 11. One ‘solution’ to infertility is assisted reproduction and we look at that in chapter 12, before considering why you may decide against it in chapter 13. A common problem for Christians pursuing assisted reproduction is deciding what to do with leftover embryos. Options are discussed in chapter 14. Chapter 15 on human embryo research, stem cells and cloning helps clarify some of the options available to parents in this situation.

In the midst of all the discussion about assisted childbirth, we need to take time to consider whether it is ethical for Christians to embrace modern technology in the quest for a child. After all, if God had wanted us to be parents he could have made it happen naturally, couldn’t he? When is it permissible to take things into our own hands? We look at this in chapter 16.

We end by considering how the Christian view of the value of unborn human life has changed over the ages, and whether pastors need to rethink the guidance they offer their members in the new millennium.

The appendices allow us to consider in more depth a few issues raised in the text: whether the oral contraceptive pill causes abortions, what are the commercial markets created by abortion, advances in the study of human genetics, and what is meant when someone asks you if you want your baby’s cord blood cells collected at birth.

Many of the papers and journal articles I refer to in the footnotes—and even some of the books—are available online and can be freely read or downloaded. Internet search engines are great tools for this purpose, and I encourage you to follow up on those references that interest you.

I think it is important that in all our discussion of these topics, we remember that we will touch on painful issues for real people who have had to come to terms with terrible sadness in their lives. My prayer is that this information will help those who are making decisions, and those who are supporting them, to bring glory to God.

  1. J Budziszewski, in ‘Contraception: a symposium’, First Things, December 1998, pp. 17-29. 


One of the difficulties in discussing the morality of medical technology is that in order to understand the ethics, we first need to understand the technology and the science that underlies it. In this chapter, I am providing a biology lesson to remind us how life begins at fertilization. I will also examine arguments that suggest human life begins after fertilization.

Human development

Human conception begins with fertilization of an egg[1] by a sperm. Cells in the human body have 46 chromosomes, made up of 23 pairs. Chromosomes carry the genetic material, or DNA (deoxyribonucleic acid), that guides our individual growth and development. Both the egg and sperm carry half the usual number of chromosomes, so their union creates a single cell with the full complement of chromosomes. This single cell is called a zygote and has its own unique genetic code.[2] Both the sperm and the egg cease to exist individually at this point. It is not a ‘fertilized egg’ so much as the first cell of the new human, physically representing the ‘one flesh’ (Gen 2:24) of the father and mother. All the genetic material required for full maturity of the human being is present in this single cell, and from this point on it will direct its own growth. From this point, development of the individual will be a continuum through pregnancy and childhood to adulthood. We therefore have in the human zygote a member of the species homo sapiens.

A human being is conceived when a sperm penetrates the wall of a human egg, which normally happens in a woman’s fallopian tube.

Female reproductive organs
Early embryo development

The first cell division occurs within 24 hours of conception, and cellular division continues while the embryo travels down the fallopian tube towards the uterus.[3] At day 5 a blastocyst is formed, at which point the cells have divided into those which will become the baby and those which will become the placenta; an inner cell mass surrounded by a hollow ball of cells. The blastocyst will normally be floating in the uterus at the end of the first week, when implantation begins. The blastocyst attaches to the uterine wall and the mother’s blood supply starts to nourish it. Sadly this doesn’t always happen successfully and instead an early miscarriage occurs.

At around 14 days, the mother will notice that she has missed her menstrual period—the first outward sign of the pregnancy. Embryonic development from this point is quite rapid. Note that babies can vary in their development and the information below is a rough guide only, counting weeks from fertilization.[4]

Table 1: Human embryological development

Age (weeks)

Length (mm)[5]




Future spinal cord begins to develop and heart tubes begin to fuse. Blood cell production begins.



The embryo’s own heart begins to beat regularly. Early development of the brain, thyroid, eyes and ears, arms and legs. Embryo begins to curve into typical C shape.



Continued development of eyes and mouth, arms and legs. Nose, sinuses, lungs, and hands begin to grow.



Beginning of formation of feet, ears, nipples and bones. Continued development of face and brain. Fingers are growing on hands and toes on feet.



Trunk lengthens and straightens. Upper limbs are longer and bent at elbow. Hands approach each other, feet likewise. Kidneys and tastebuds start to develop. Hormones are beginning to be produced by the embryo.



Eyelids and external ear more developed. Limbs longer and more developed. Beginnings of all essential external and internal structures are present.

You can see that even while still at the embryonic stage (that is, from 0-8 weeks), an enormous amount of development has taken place. After 8 weeks, the fetal period begins. At 3 months, the fetus is fully formed and all organs are beginning to function. The remainder of the pregnancy is the time during which the fetus will mature.

Table 2: Human fetal development

Age (weeks)

Crown-rump length (mm)[6]




Eyes closing or closed. Head more rounded. Intestines are in the umbilical cord.



Intestines in abdomen. Early fingernail and bone development. The fetus can move spontaneously when seen on ultrasound. Fetus begins to swallow amniotic fluid.



External genitalia distinguishable as male or female. Well-defined neck. Tastebuds mature. Kidneys start to make urine. Fetal chest wall movements are starting.



Head erect and lower limbs well developed.



Ears stand out from head.



Early toenail development.



Head and body (lanugo) hair visible.



Skin wrinkled and red. Eyebrows and eyelashes usually recognizable.



Fingernails present. Lean body. May be able to suck and hear.



Eyes partially open. Eyelashes present.



Eyes open and sensitive to light. Good head of hair. Skin slightly wrinkled.



Toenails present. Body filling out. Testes descending.



Fingernails reach fingertips. Skin pink and smooth.



Body usually plump. Lanugo hair is disappearing. Toenails reach tips of toes.



Prominent chest; breasts protrude. Fingernails extend beyond fingertips.


I have noticed in my research that language is often used to confuse the debate regarding when life begins. Depending on your purpose, early embryos can be called many things, including ‘pre-embryos’, ‘fertilized eggs’, ‘pre-syngamy eggs’, ‘little clusters of cells’, and ‘genetic material (which is going to be thrown away)’. And the problem isn’t just euphemisms for early embryos; I have also seen the term ‘conception’ used to describe the beginning of fertilization (fusion of sperm and egg), the end of fertilization (syngamy), full genetic expression (around the 8-cell stage) and implantation (around 7-10 days). Then there are various options for the term ‘cloning’: we have ‘therapeutic cloning’ (which sounds downright good for you), ‘cloning for research’ (which also sounds fairly harmless), and ‘somatic cell nuclear transfer’ (which for most people means nothing at all). Although the technical terms can be difficult for those not used to them, there is a lot to be said for clarity. Any terms that obscure the truth instead of increasing transparency should be avoided.

Common objections to the argument that human life begins at fertilization

In public debate, no educated person questions the humanity of the human embryo any more. The argument now focuses on when the embryonic human deserves protection. Nonetheless, despite the straightforward embryology, you may still hear arguments that suggest the embryo is not human.[7] I have listed the most common of these below, along with a response to each one.[8]

1. Twinning and the problem of individuality

This objection states that, because it is possible for an embryo to divide into two identical twins, or indeed (rarely) for two embryos to meld into one, and because the early embryo is totipotent (each individual cell retains the capacity to develop into a separate embryo), it is not possible to say that a single human individual exists from zygote stage (because you could end up with two). It is argued that it is only at around 14 days, when totipotency and the possibility of twinning no longer exist, that the human individual exists.

Response: This argument confuses individuality with indivisibility. While most individual humans are indivisible, it is not necessary for them to be indivisible in order to be human individuals. Consider conjoined (Siamese) twins. Despite the fact that they are permanently joined, we talk about them as two persons rather than one. In any case of fertilization, an individual embryo exists from day one. It may or may not divide during the next two weeks. At present we don’t know enough about the twinning process to be able to know from day one whether or not the embryo will divide. However, the possibility of division does not remove the fact that the individual embryo exists. Should it divide, then two individuals exist. The existence of one has begun in a way that is unusual for a human being (i.e. twinning), but this does not alter the fact that it has begun to exist as an individual. The other embryo continues to exist, as it has since day one, maintaining its identity (ontological continuity) for the rest of its life. The unusual process of generation does not change these facts, and our inability to identify which is the ‘new’ embryo and which is the ‘continuing’ embryo also does not change these facts. The objection that two embryos can become one (mosaicism) can be responded to in the same way.[9]

2. The problem of destiny

This objection notes that most of the substance of the early embryo does not contribute to the future fetus. The developing cells of the embryo do not separate into those that will become the embryo and those that will become the extraembryonic membranes (such as the placenta) until the blastocyst stage, and all tissues supporting the development of the fetus are discarded at birth. How can we call the early embryo a human being when this excess tissue makes up more than half of it?

Response: Our inability to distinguish those cells that will become the body from those cells that will become the placenta after the first week does not change the fact that a human individual is represented in an early embryo. It is just a human individual with extra tissue. The lack of clarity should make us more careful in our handling of it—not less.

3. The problem of wastage

It is estimated that roughly up to 75% of all embryos created naturally will fail to implant after fertilization, often without the woman ever being aware that she was pregnant. It has therefore been suggested that the destruction of human embryos which is sometimes part of the reproductive technology process is the equivalent of this normal ‘wastage’, and therefore of no moral concern. This argument suggests that the sheer number of lost embryos in either process reduces the significance of each individual one.

Response: It is true that there is a high rate of loss of human embryos before natural implantation (the range is 30%-70%). This is frequently due to a genetic abnormality, such as the wrong number of chromosomes or missing/extra bits of chromosomes, which can be fatal for embryos. Other reasons that some embryos don’t make it include local endometrial (womb lining) factors affecting receptivity to the blastocyst; or a lack of energy in the embryo due to mitochondria problems, especially if they were made from an older woman’s eggs (the mitochondria is the ‘power house’ of the cell). However, this is not an expression of the unimportance of early embryos so much as a problem of living in a fallen world. In countries where many children die before 12 months of age, you would not consider each child less important, but as a casualty of disease in a fallen world. You certainly would not say they weren’t human. Furthermore, how can a statistical argument (which speaks in percentages) give us a sufficient indication of discontinuity in the individual embryo to justify destruction?[10] As we do not know in advance which embryos will live and which will die, we need to treat them all carefully.

4. The problem of environment

This is really an extension of the ‘wastage’ argument. It is suggested that until implantation, the embryo is not in a secure environment where nurture is ensured. In the 10 days or so before implantation, the embryo could still be flushed out of the uterus with the next menstrual flow and there is no guarantee that it will remain in an environment where it will be able to flourish.

Response: Location is not a biologically significant factor when deciding what an embryo is. It is either a human being or not, regardless of where it is. None of us would survive long if we were not in an environment conducive to our survival.

5. The problem of syngamy

The continuity of the human being from fertilization is linked to its unique genetic code (DNA), which results from the fusion of egg and sperm. However, as we have discovered more about the embryo we have realized that fertilization is not so much an event as a process. We now know that there is a gap of about 20 hours between the penetration of the egg by the sperm and the total fusion of male and female DNA (syngamy). It is suggested that if personhood is linked to the genetic continuity of the individual from embryo to live birth, then the human embryo should be protected only once syngamy (and therefore fertilization) is complete.

This may seem petty—arguing over a few hours time difference—but it is significant because some scientists want to conduct research into aspects of fertilization that occur before syngamy (for example, the microinjection of a single sperm into the egg). This has led to a change in the definition of an embryo in some jurisdictions so that it is said to exist only after syngamy has occurred.

Also, a few hours before syngamy, the genetic material from the sperm and the egg are visible as separate vacuoles (storage bubbles) called pronuclei. Some ART[11] clinics offer the service of freezing embryos at this stage (they may call the embryos ‘fertilized eggs that have not yet become embryos’) to avoid producing more ‘embryos’ than will be used, yet still have the benefits of freezing.

Those who believe that legislation should protect the human embryo only after syngamy is complete are not necessarily arguing against the view that a new human life begins at fertilization. Rather, they may be attempting to explain the traditional view more precisely.

Response: There are many points at which the embryonic human life is said to have begun: on penetration of the egg by the sperm; at syngamy; on implantation; at viability; and at birth. Certainly there are significant milestones reached at each of these points, and each milestone is necessary for the ongoing development of the human being involved. However, the first ‘significant moment’ is when a particular sperm penetrates the egg so that the sperm and the egg individually no longer exist. At this time the structure of the egg wall changes so that no other sperm can enter. This is the moment when the unique combination of genetic material of the new individual is first together within one cell, and all other genetic combinations (had a different sperm won the race) are no longer possible. The gender of the embryo is decided. To choose any later ‘significant’ point is arbitrary.

Although it is possible for the normal sequence of events in fertilization to fail in some way—for example, more than one sperm may enter the egg—this is unusual and leads to significant abnormalities in the embryo. I would not change my definition of the embryo on this basis. We create definitions based on the common manifestation rather than the exception. So while it is possible for a man to have one leg, he usually has two. We would not say he was not a man because of this difference, nor would we refrain from defining ‘man’ as a two-legged creature because an exception is possible.[12]

We also know that the beginning of fertilization (prior to syngamy) is significant in other ways. The organization (orientation) of the embryo’s development seems to be present from the start, and may be related to the sperm’s point of penetration.[13] In addition, the embryo is a separate organism that will direct its own growth and development from that point on.

Furthermore, the argument from syngamy seems to me to be trying consciously to follow the letter of the law while avoiding the spirit of the law. We all know that a human being comes from the joining of the sperm and the egg. If it is not a nascent human being prior to syngamy then what is it?

6. The problem of potential

This argument concedes that the early human embryo has the potential to develop into a fully conscious human being, but denies that this potential means it deserves to be given moral significance. This argument does not grant moral significance on merely biological grounds.[14]

Response: The words used in ethical debates can make a difference to how the community thinks. One problem of discussing embryos in terms of ‘potential’ is that it gives us the impression that the embryo is not fully human, when what is meant is that it is not fully developed. It would be more helpful to describe an embryo as a ‘human with potential’ than as a ‘potential human’.

However, this helps us clarify some of the confusion. If we mean that the embryo will become a fully conscious human, it would be fair to say we imply that the embryo is not fully a human being yet. But that is not what I mean when I say an embryo deserves protection because of its potential. I am indicating that there is continuity between the embryonic human and the fetal human and the child human and the adult human. This is referred to as ontological continuity. We were all embryos once. And when we were, we looked exactly like an embryonic human is supposed to look.

We should also remember that in biblical terms, no-one reaches their potential in this life. Philippians 1:6 tells us that God is still working in each one of us. In this sense, we are all ‘humans with potential’ until we are face to face with God.

7. The problem of appearance

According to this argument, early embryos are not human because they do not look human. For one thing, they are very small (smaller than a full stop). They are also a different shape, and they can’t do anything.

Response: It is obviously true that embryos in the first month of development look different from the way we do now. But you also look different now from the way you did one month after birth. You may not like it, but that’s what you looked like at that stage of development. It does not help us determine what your moral value is. Appearance is not morally relevant.

8. The problem of detection

This argument notes that there is no test for the mother to identify that an embryo has been created until after implantation when her human chorionic gonadotropin (hCG) level is checked. Therefore, it is claimed, the pregnancy (and by implication, human life) cannot start until then. This argument is sometimes expanded to include the idea that ‘conception’ is a process that begins with fertilization and ends with implantation, and cannot be said to have definitely occurred until the embryo is implanted in the mother’s womb.

Response: This argument seems to be saying that something cannot exist if you can’t confirm it with a test. Indwelling Holy Spirit aside, years of scientific research should have taught us by now that just because you can’t detect something, it doesn’t mean it’s not there. It would make sense that there are no biochemical markers detectable in maternal blood before the embryo physically attaches to the wall of the mother’s uterus and makes contact with her blood supply. (In much the same way, there is no evidence I have taken medication until it is absorbed into my system, but that doesn’t mean the tablet is not in my tummy.)

Perhaps this argument supports the idea that pregnancy begins with implantation, but our inability to test for the embryo’s existence prior to this does not mean that human life begins at implantation. There was a time when English law did not confidently extend protection to an unborn child until the mother felt it move (known as ‘quickening’) because that was how they knew it was definitely there. Times change. Perhaps we should simply say that we cannot routinely detect the presence of an embryo in the womb prior to implantation yet.

However, it so happens that studies have demonstrated that hCG in the mother’s blood is not the earliest signal of pregnancy. Although the test has only been done in research laboratories, Early Pregnancy Factor (EPF) has been detected in maternal blood within 24 hours of fertilization. It is thought that the embryo releases EPF to prepare the nearby endometrium for implantation.[15] This may yet provide us with an earlier test for pregnancy, but technically it is quite difficult to do.

It is also important to realize that the existence of embryos fertilized outside of the body (as in the case of IVF) is not questioned just because implantation has not occurred. Their importance may be questioned, but not their existence as embryological human beings. If confirmation of existence is the requirement for humanity, on these grounds embryos are human beings before implantation.

9. Difference in kind

This is more of a moral significance issue, discussed by philosopher Michael Sandel in the prestigious New England Journal of Medicine.[16] Using the analogy of an acorn and an oak tree, he argues that just as we do not value an acorn as much as an oak tree, so we do not need to value embryos as we would adult human beings. He dismisses the developmental continuity, saying that embryos and adult humans (like acorns and oak trees) are different kinds of things and so do not have the equivalent moral value.

Response: It is important to note that human beings and oak trees are not moral equivalents. Indeed, it is because of the kind of thing it is that we value an adult human more than an oak tree. In the same way, it is because of the kind of thing it is that we value a human being at all stages of development. Made in the image of God, our value lies in what we are rather than in what we can do. It is our essential nature that gives us moral value. In contrast, the reason we value an oak tree over an acorn is because of what RP George and C Tollefsen call its “accidental characteristics”—the shade it provides, its magnificence and perhaps its sentimental value.[17] These ‘accidental characteristics’, and not its essential nature, explain why an oak tree might be valuable to us—indeed, why a large, beautiful, oak tree would be highly valued while a small, ugly one would not.

The oak tree analogy does not work, although it does help us understand that when we grieve the loss of an adult more than an embryo, it is because of the ‘accidental characteristics’ of the human adult with which we have become familiar as we have been in relationship with them. Just because the embryo and adult human have equivalent moral value does not mean they are identical. I would suggest it is not true that loss of a human embryo is never mourned,[18] but it is certainly mourned less, on the whole, than loss of a more mature human.

10. Confusion with gametes

I have heard many arguments where embryos are confused with gametes (sex cells; sperm and eggs). It is argued that if sperm and eggs are alive but are not treated as if they are human, why should embryos be treated as if they are human? The reverse is also argued: that if we treat an embryo as if it is morally significant, why would we not have to treat sperm and eggs just as carefully?

Response: As mentioned above, sperm and eggs each consist of a single cell that is different from other types of cells in the body. Each has a half complement of DNA (genetic information)—that is, they have 23 chromosomes each rather than the usual 46. As such, they cannot grow individually as they do not contain all the required genetic material for maturation. Therefore, neither is a human being at an early stage of development, and so neither has moral significance. When the egg and sperm combine to make a zygote, however, a cell is created with a new set of the full 46 chromosomes—a unique individual with its own unique genetic code, combining the mother and father’s DNA in a new way. This cell also has the ability to continue to divide and direct its own development from that point until it is a fully grown human. As a genetically distinct human being even at this early embryonic stage, it has moral value.

11. Confusion with somatic cells

Following on from the previous argument, it has been suggested that if the other cells in the body apart from the sex cells (called somatic cells) each have 46 chromosomes just like an embryo, and we now know that they can each grow into an embryo through the cloning process, then it follows that every cell in the human body has as much potential for development as any human embryo. Therefore it is suggested that embryos have no greater significance than ordinary somatic cells. And since we obviously don’t treat every cell in our body as morally significant, it is argued, we shouldn’t give this status to an embryo.

Response: This is, once again, a mistake in biology. Although an embryo can be generated from a somatic cell through the cloning process, the somatic cell of itself is not a distinct organism, and is only able to change into an organism with the introduction of other factors.[19] In contrast, a human embryo is of itself a “unified, unique, dynamic, self-directed whole”,[20] distinct from other organisms, as soon as it is created. A similar argument to this—that stem cells are equivalent to embryos because they can also be used to create an embryo—can be refuted on the grounds that, once again, a stem cell cannot of itself develop into an individual organism.

Having said that, if a human embryo were to be created through any of the cloning techniques, it would deserve to be treated with respect similar to that of a human embryo that was created by fertilization, just as we treat other human beings whose beginnings were atypical with similar respect. But by that stage it is no longer a somatic cell or a stem cell.

The strange case of the clone

How can a cloned embryo have the same moral status as a fertilized embryo? Isn’t the definition of a human embryo based on sexual reproduction—the joining of a sperm and an egg? Now that we can make ‘embryos’ from single cells (with a bit of extra help—asexual production), what does that mean in terms of moral significance? Are they the same kind of thing?

Yes. Despite their different origins, once you have created an embryo that continues to promote and direct its own growth, the two types of embryo are indistinguishable. You could only identify the clone genetically by showing that its DNA was the same as another person’s (this is the definition of a clone). Furthermore, the development of the two types of embryos will be a continuum through pregnancy to birth and further growth. Should any children come to birth through asexual production they will be fully human, made in the image of God, and morally valuable.

12. The problem of Christian apathy

According to this argument, human embryos should not be treated as morally significant human beings today because they have been routinely destroyed for years through the use of certain contraceptives and the development of assisted reproduction, and the church has not made any significant objection to this in the past.

Response: Ouch. It is true that we have failed to protect human embryos, those most vulnerable of human beings, in the past. This reflects not so much on the nature or value of those embryos as on our own indifference. Maybe we should change. We will address this issue below—but for now, I will end this section by directing you to the real experts.

The view of embryologists

Embryologists are the experts in this field. They are quite clear about what fertilization represents. There are many references I could quote to make the point; here are just some:

Almost all higher animals start their lives from a single cell, the fertilized ovum (zygote)… The time of fertilization represents the starting point in the life history, or ontogeny, of the individual.[21]

Embryologist Ronan O’Rahilly originated the international Carnegie Stages of human embryological development, used for many decades now by the international Terminologica Embryologica committee, which determines the scientifically correct terms to be used in human embryology around the world. This internationally pre-eminent human embryologist has no doubt that in biological terms we are dealing with a human being from the time of fertilization:

Although life is a continuous process, fertilization… is a critical landmark because, under ordinary circumstances, a new, genetically distinct human organism is formed when the chromosomes of the male and female pronuclei blend in the oocyte [egg]. This remains true even though the embryonic genome is not actually activated until 2-8 cells are present, at about 2-3 days…

During the embryonic period proper, milestones include fertilization, activation of the embryonic genome, segregation of embryonic from extra-embryonic cells, implantation, and the appearance of the primitive streak and bilateral symmetry.

Despite the various embryological milestones, however, development is a continuous rather than a saltatory process, and hence the selection of prenatal events would seem to be largely arbitrary.[22]


Prenatal life is conveniently divided into two phases: the embryonic and the fetal…

…it is now accepted that the word embryo, as currently used in human embryology, means “an unborn human in the first 8 weeks” from fertilization. Embryonic life begins with the formation of a new embryonic genome (slightly prior to its activation).[23]


The embryo, from the time it is created, is a unified, unique, dynamic, self-directed whole, not just a collection of cells. There is evidence that organization exists from the first cell division.[24]

So if there is no doubt that, biologically, the human embryo is indeed a human being at an early stage of development, why is there confusion about how it should be treated? We shall consider this question in the next chapter.

  1. The correct term for the human female gamete is ‘oocyte’. However, even though it is a more culinary term, ‘egg’ is used here for familiarity. 
  2. For a more detailed explanation of human genetics, see appendix III. 
  3. The first week of embryo development is covered in more detail in chapter 12. 
  4. Working out the duration of pregnancy can be confusing, as some people date it from the first day of the last menstrual period (this is known as gestational age, which actually starts counting before fertilization takes place). This was traditionally used because most women know this date. Embryologists describe development in ovulation age (time from ovulation) or postconceptional age, which is used here. You can translate this number into gestational age by adding two weeks to the postconceptional age. For greater detail of embryology see R O’Rahilly and F Müller, Human Embryology and Teratology, 3rd edn, Wiley-Liss, New York, 2001; for fetal development see F Cunningham, K Leveno, S Bloom, J Hauth, D Rouse and C Spong, Williams Obstetrics, 23rd edn, McGraw-Hill, New York, 2010, chapter 4. 
  5. From 3-5 weeks greatest length is given; from 6 weeks crown-heel length is given. 
  6. Average measurements are given, variation increases with age. 
  7. Some of these arguments are also used to deny the moral significance of the unborn human. 
  8. I have heard these arguments from many sources and have not listed them all. This topic is treated in great detail in RP George and C Tollefsen, Embryo: A Defense of Human Life, Doubleday, New York, 2008. 
  9. Further discussion is found in JJ Davis, ‘Human embryos, “twinning”, and public policy’, Ethics and Medicine, vol. 20, no. 2, Summer 2004, pp. 35-46; and J Finnis, ‘Abortion and Health Care Ethics’, in R Gillon (ed.), Principles of Health Care Ethics, Wiley, Chichester, 1994, pp. 547-57. 
  10. See O O’Donovan, Begotten or Made?, OUP, Oxford, 1984, p. 57. 
  11. Assisted reproductive technology. 
  12. This point is challenged in S Buckle, K Dawson and P Singer, ‘The syngamy debate: When precisely does a human life begin?’, Law, Medicine and Health Care, vol. 17, 1989, pp. 174-81. 
  13. The very early development of the embryo is still not fully understood. See T Hiiragi, VB Alarcon, T Fujimori, S Louvet-Vallée, M Maleszewski, Y Marikawa, B Maro and D Solter, ‘Where do we stand now? Mouse early embryo patterning meeting in Freiburg, Germany (2005)’, International Journal of Developmental Biology, vol. 50, no. 7, 2006, pp. 581-88. 
  14. This argument is expanded in S Buckle, ‘Arguing from potential’, Bioethics, vol. 2, no. 3, July 1988, pp. 227-53. 
  15. H Morton, AC Cavanagh, S Athanasas-Platsis, KA Quinn and BE Rolfe, ‘Early pregnancy factor has immunosuppressive and growth factor properties’, Reproduction, Fertility and Development, vol. 4, no. 4, 1992, pp. 411-22. 
  16. MJ Sandel, ‘Embryo ethics: The moral logic of stem-cell research’, New England Journal of Medicine, vol. 351, no. 3, 15 July 2004, pp. 207-9. 
  17. Full discussion of this argument can be found in George and Tollefsen, op. cit., pp. 176-84. 
  18. See ‘Moving on’ at the end of chapter 12. 
  19. For further discussion of cloning, see chapter 15. 
  20. H Pearson, ‘Developmental biology: Your destiny, from day one’, Nature, vol. 418, no. 6893, 4 July 2002, pp. 14-15. 
  21. BM Carlson, Patten’s Foundations of Embryology, 6th edn, McGraw-Hill, New York, 1996, p. 3. 
  22. O’Rahilly and Müller, op. cit., p. 8. 
  23. ibid., p. 87. 
  24. Pearson, loc. cit. 

The moral status of the embryo

During the 2002 public debate in Australia about whether destructive research on human embryos should be allowed, I remember reading the newspapers with frustration. In the same week, different reports claimed that the frozen excess embryos in question were: (a) dead; (b) merely human cells; and (c) not human at all. These are all incorrect, though (a) involves an interesting metaphysical question.[1]

Thankfully those days are over, and we no longer need to argue in informed circles that human embryos are indeed embryonic humans. The question we now face in public policy is: at what stage of development does the nascent human deserve protection? It is the answer to this question that has informed our community’s treatment of unborn humans, and therefore the way medical practice has developed. However, the question is complicated, not only by the differing definitions used by each side of the debate, but also by how each party decides what is and is not ethically permissible. Our motives also complicate the discussion—it has long been recognized that people tend to choose their definition and select their preferred moral calculus according to the result they want to achieve.[2]

We have examined the biological view in the previous chapter, which demonstrated the undeniable humanity of the embryo in physical terms. However, human beings are more complex than just biology, and as we have already mentioned, biological facts do not determine moral significance. In view of this, how has our society justified the destruction of unborn humans at embryonic and fetal stages? The answer lies in the way the developing human is considered in philosophical terms.


The proponents of destructive embryo research and abortion usually advocate that protection is only due to human persons, and that personhood is not conferred merely on biological grounds. The modern view is that the status of ‘personhood’ is not automatically given to any human being, but only to those who can perform certain functions. It is worth pausing here to look a bit closer at the idea of personhood’.

The concept of human personhood has been incorporated into Christian doctrine since its earliest writers, to express the biblical understanding of individuality. Boethius (480-524 AD), in his Fifth Tractate, coined the traditional definition of a person—“the individual substance of rational nature”—to defend the Chalcedonian definition of Christ as “one person in two natures”. The substance (a person) is separated from a specific property, its nature (human/divine).[3] For much of its history, this definition of personhood was understood to mean ‘an individual (human) being of a rational nature’. As explained by Thomas Aquinas, the classical understanding was that those who possess a human nature possess a rational nature, even if they are unable freely to exercise their reason at a certain time (for example, it they are too young). Therefore, it was considered that all human beings were human persons.

During the 20th century, the definition of personhood underwent a change, largely for political reasons. Over time, the origins of Boethius’ definition were lost, and it began to be interpreted as meaning that a person was merely a particular instance of a rational nature. The ‘nature’ gradually became more important than the ‘substance’.

In 1954, Episcopalian minister Joseph Fletcher published an account of human personhood in which he claimed that the human person must not merely possess a rational nature, but be able to exercise it. His motivation was a desire to justify legal abortion, which at the time was seen by some Christians as an expression of compassion toward women in a difficult situation (unwanted pregnancy).[4] This was at a point when the birth control movement had shifted the focus of the abortion debate away from the humanity of the fetus. Fletcher’s definition was driven less by scientific discovery and more by the political debate around abortion. If the embryo was not a fully human person then abortion would be much easier to justify.

Fletcher argued that what sets humans apart from other animals is their possession of reason. He claimed this is what grounds human dignity and is signified by the term ‘person’. He went on to argue that if the human embryo is not a human person then it does not merit legal protection. His approach is based on the work of the English philosopher John Locke, focusing on the actual intelligence and reflective powers that people can display, and requiring someone to have a high degree of self-awareness before they can be defined as a ‘person’. For Fletcher, the possession of human nature with the latent ability to reason was insufficient, and thus not only embryos and fetuses but also newborn infants would have to be classed as non-persons. He explicitly accepted the conclusion that infanticide would be justifiable on these grounds. Those in a prolonged coma or suffering dementia would likewise be excluded from personhood status. Technically, you would also have to exclude a perfectly normal adult who was asleep or unconscious, because their reasoning is also latent.[5]

In response to this argument, many people (Christians especially) would suggest that surely this is an unacceptable way to decide which humans deserve protection in our legal system. Obviously, any ethic allowing infanticide is not consistent with the Christian desire to defend the weak and helpless.

Traditionally those who are unable to speak for themselves and who thus become socially vulnerable are seen to be in more need of protection rather than less, which suggests that we should stick with the standard definition of ‘person’—that is, a living human being. If you are a human being, you possess a human nature, which means you have a rational nature even if you are unable to express it at the time.

There is some concern (amongst Christians especially) that attempts to redefine personhood are a foil aimed at political expediency—in this case, to allow the destruction of human embryos for research. Arguments about ‘personhood’ certainly became more important once embryos were created in isolation for use in IVF. Suddenly the focus was more on what the embryo actually was in and of itself, rather than just its importance in relation to the mother.

There are many theories regarding the point at which personhood begins, or when independent moral status is acquired. Generally these theories require the unborn child to have particular features or abilities before being considered worthy of protection. Some of these views are summarized below in table 3.

Table 3: Personhood theories

Point at which personhood begins Rationale Noted proponents
Fertilization Genetic union of parental gametes (one flesh) and continuum of self-directed development from this point Embryologists and many Christians
14 days Primitive streak visible in embryo; twinning no longer possible Warnock committee 1984, United Kingdom Parliament (see below)
Implantation Embryo is in an environment where maturation will occurorDefinitional change[6] Many obstetricians and gynaecologists
Quickening (first time at which mother is aware of fetal movement; 17-20 weeks) Confirms presence of fetus Medieval writers
Sentience (capacity to feel pain) Includes higher-order animals Philosophers LW Sumner and Peter Singer, and some animal rights activists
Viability (ability to survive outside the womb; varies with geographical location; 22+ weeks) “With respect to the State’s important and legitimate interest in potential life, the ‘compelling’ point is at viability”[7] Supreme Court of the United States in Roe v. Wade
Birth Physical independence from mother Most Western federal courts
Self-consciousness “Life without consciousness is of no worth at all”[8] Philosophers Peter Singer and Michael Tooley

Public debate on these competing theories continues without any sign of resolution. My main objection to the claim that personhood begins at any point after fertilization is that these are arbitrary points. Yes, each one of these points is a significant milestone in the life of the human involved. But there will be many more significant moments that come afterwards. Once you go beyond fertilization, that’s all it is: the next stage of development, then the next, one after another.

Some of the ‘requirements’ for personhood listed above are not actually intrinsic properties of the fetus. For example, in pre-ultrasound times quickening (the first movements of the fetus felt in the uterus) was used to confirm that a live baby was present. But the timing of quickening varies according to the sensitivity of the pregnant woman, with first-time mothers regularly noticing fetal movement later than their more experienced sisters. And viability depends on biology and the standard of care available. The gestational age for viability keeps changing as technology in neonatal intensive care units improves. Likewise, the timing of birth can be dependent on a host of factors outside of the baby itself.

The idea of personhood that has most influenced international debates on human embryo research is that proposed by the Warnock committee, which reported to the United Kingdom government in 1984. While acknowledging that embryonic humans should have a special status, the committee decided to avoid answering the question of when life or personhood began. Instead it discussed how the embryo should be treated. Despite criticisms of this approach (how do you know how to treat it if you don’t know what it is?), the committee’s recommendation—that destructive human embryo research can be justified up to 14 days—has influenced policy makers around the world ever since. The introduction of in vitro (in the test tube) fertilization (IVF) in the United States was also approved after ‘putting aside’ the question of the moral status of the embryo.[9] Interestingly, at the time IVF was approved, the maximum length of time anyone had been able to grow human embryos in the laboratory was 14 days. How convenient.

The Warnock committee conferred emerging personhood on the embryo—that is, they indicated that personhood increases with age. They chose their time limit for destructive embryo research on the grounds that 14 days was the time when the primitive streak was visible in the embryo (“this marks the beginning of individual development”),[10] and also the time when twinning was no longer possible.[11] We now know that this science is out of date. Subsequent research has shown that the human embryo is organized from its very first day.[12] However, the Warnock report remains influential. Its assumptions permeated the United Kingdom’s most recent review of the Human Fertilisation and Embryology Act in 2005;[13] and the ‘14-day rule’ has been confirmed as an ethical principle by various government ethics committees, including United States federal committees[14] and Australian parliamentary reviews.[15]

The interesting thing to notice in the literature about the moral status of the embryo is that most philosophers—regardless of whether they think the embryo deserves protection or not—do not support the arguments used in the Warnock report to justify the ‘14-day rule’.[16] According to the philosophical literature, either the pre-14 day embryo is being unjustifiably exploited (because it deserves protection), or research on embryos is being unjustifiably limited (because they don’t deserve protection until later).

How do we decide which is correct? Certainly not by asking the researchers. The moral status of the human embryo is not a scientific question but a philosophical or metaphysical one, dependent on one’s world view rather than calculated by an equation. It does not lend itself to numerical values and deadlines.

Proponents of destructive embryo research further justify their position (that the human embryo does not deserve protection) by pointing to examples in modern life where our society already condones the discarding of embryonic and fetal humans. These include the marketing of contraceptives that work after fertilization, assisted reproductive technology (ART) research, and legal abortion.[17] The high rate of embryo loss before implantation in normal pregnancy is also considered to support this view.[18]

Despite the time given to discussions of personhood, it’s hard to avoid the impression that its place in the debate is really an excuse to justify what some people want to do anyway.

The philosophical theory that underlies the position that approves of human embryo destruction is ultimately consequentialism. Consequentialism is the ethical theory that right and wrong can be determined by looking at the consequences of our actions alone (leaving out consideration of things like motives, intentions, actions and the character of the person involved). Many national governments have decided that while the destruction of developing humans (usually in the form of excess frozen embryos left over from assisted reproduction) may be regrettable, the consequences of their destruction is sufficient justification—for example, potential medical cures through embryonic stem-cell research, babies through ART research, and freedom for women desiring abortion.

Yet the secular world is not entirely committed to the idea that early human life is unimportant. The Warnock committee recognized the mood of the community when they “agreed that the embryo of the human species ought to have a special status”.[19] However, without biblical grounding, many people are unsure as to why this should be so. One secular expression of the preciousness of human life is reflected in human rights declarations, which since World War II have been designed to protect the welfare of human research subjects. Technically, destructive research on human embryos contravenes documents such as The Nuremberg Code[20] and the WMA Declaration of Helsinki, which requires that “in medical research involving human subjects, the well-being of the individual research subject must take precedence over all other interests”.[21] The Council of Europe Convention on Human Rights and Biomedicine ensures “adequate” protection of the embryo where in vitro research is allowed (although I’m not sure exactly what “adequate” includes), and also prohibits research on human embryos in vivo (in the body) and the creation of human embryos for research.[22]

However, when economic opportunity and political expediency call, such documents may fail to impact legislators. In Australia, amidst concerns expressed in the media that lucrative biotechnology opportunities would be lost if embryonic stem-cell research was not approved by parliament, laws were passed in 2002 to allow it—despite a previous Senate committee recommendation that human embryos be protected from destructive experimentation.[23] It is interesting that in Western Europe, countries that witnessed the worst of the World War II atrocities, such as Germany and Italy, have been among the most reluctant legislatures when it has come to approving destructive research on human embryos.

Another group that has decided fetal life can be valued without establishing formal independent moral status is a body of doctors involved with antenatal care.[24] Chervenak and Kurjak have argued that if a human being is presented to the physician, and if that human is expected to benefit from the application of the physician’s clinical skills, then that human being can be viewed as a patient. Certainly many doctors who work with newborn babies hesitate to advocate abortion once they realize how similar their tiny patients are to those in the womb.

Chervenak and Kurjak’s arguments ground the value of the fetus in the ontological continuity of its identity with the human who is reliably expected to achieve independent moral status later, after birth. While they respect the autonomy of the pregnant woman, they note that her expectation that the doctor will care for the child is expressed in her presentation to the doctor for antenatal care in the first place. They recognize the possibility of conflict should the mother refuse the physician’s advice, but suggest that beneficence (doing good) towards the baby should be their motivation, in balance with obligations to the mother (for instance, in regard to her safety). They endow the unborn child with moral significance by referring to codes of professional medical ethics. Those who take the Hippocratic Oath (historically the most influential declaration of the moral obligations of the medical practitioner) specifically promise not to “give a woman means to procure an abortion”.[25]

Despite difficulties in understanding why it should be so, the reality of our community’s instinctive attribution of special status to the human embryo is seen in the fact that in Western countries where destructive research on human embryos is legal, it requires official approval and is permitted only up to 14 days of development. There is societal hesitation to go further. Bioethicist Leon Kass, when discussing human cloning, famously referred to this hesitation as “the wisdom of repugnance”.[26] While accepting that repugnance is not a moral argument, he nonetheless sees it as “the emotional expression of deep wisdom, beyond reason’s power fully to articulate it”.[27] He expands the point:

We are repelled by the prospect of cloning human beings not because of the strangeness or novelty of the undertaking, but because we intuit and feel, immediately and without argument, the violation of things that we rightfully hold dear. Repugnance, here as elsewhere, revolts against the excesses of human willfulness, warning us not to transgress what is unspeakably profound. Indeed, in this age in which everything is held to be permissible so long as it is freely done, in which our given human nature no longer commands respect, in which our bodies are regarded as mere instruments of our autonomous rational wills, repugnance may be the only voice left that speaks up to defend the central core of our humanity. Shallow are the souls that have forgotten how to shudder.[28]

We shall return to the idea of personhood in a moment, after we have considered what the Bible has to contribute to this question.

The biblical view

Christians have a moral compass, the Bible, which should inform all our decisions regarding right and wrong.[29] We do need to understand that in issues relating to modern technology, the Bible may not specifically address the point at hand. It is an ancient collection of texts written in times vastly different from our own. Nevertheless, despite its antiquity, the Bible is God’s revelation of the unchanging principles that should guide the lives of those who follow his Son, Jesus Christ. To elicit such principles it is necessary both to pay attention to explicit biblical statements and to look for biblical themes that can inform our decision-making.

Over the years many helpful frameworks have been developed for distilling and applying the Bible’s teaching on ethical questions—see, for example, those used by Michael Hill and John Stott.[30] Most approaches suggest that the Bible’s teaching is best applied to current ethical dilemmas by considering biblical revelation in 4 stages: creation, fall, redemption and future consummation. In other words, we need to consider the world firstly as God originally made it; then as it is affected by sin; then in light of the salvation that is possible through the work of Christ; and finally in view of the glorious future awaiting us. It is important to consider the whole of Scripture in our task so that our conclusions are not distorted by a partial appreciation of God’s purposes.

In considering the Bible’s teaching on the moral status of the human embryo, I acknowledge that opinion in the Christian community is divided on this issue. After examining the texts, I will explain my own view and the reasons for it.

Creation in the image of God

We can learn a lot about the way God wants us to treat humans by considering the way we have been made. All humans are made in the image of God, and this is the basis on which we are all to be treated equally and with dignity. There has been much debate over what it means for humankind to be made in God’s image, but it at least refers to embodied individuals who live out a role in history.[31] The creation story shows us that humanity has been brought into this world by God’s creative word and, like the creation around us, we constantly depend on his will, purpose and upholding presence:

Then God said, “Let us make man in our image, after our likeness. And let them have dominion over the fish of the sea and over the birds of the heavens and over the livestock and over all the earth and over every creeping thing that creeps on the earth.”

So God created man in his own image,
in the image of God he created him;
male and female he created them. (Gen 1:26-27)

Human beings have been uniquely made in the image and likeness of God. This sets us apart from all the other creatures, which were made “according to their kinds” (Gen 1:21, 24, 25). If what qualifies you to be treated with equal dignity to others is the fact that you are a person, then all human beings have this ‘right’, for we are all persons made in the image of God. In contrast to the modern philosophical view that personhood must be earned, the Bible teaches that our personhood is inherent because of the nature of the God whose image we reflect. We are to treat all human beings with respect for the whole of their lives, regardless of their particular characteristics. It is not our respect that gives them dignity; rather, it is because they have dignity that we owe them respect.

The reality of sin and the Fall does not change this fact. Just as taking a $20 bill and screwing it up, throwing it in the mud and jumping on it does not reduce its intrinsic value (it’s still worth $20), so the ravages of sin have not reduced the value of human beings made in the imago dei. Man still retains the image of God (Gen 9:6).

When God said ‘Let us make man in our image’, and then created ‘man’ to be both man and woman, he underscored our need for community and relationships (reflecting the differentiated unity of the Godhead). In other words, we have been made for relationships both with him and with each other. This is further emphasized by the fact that when the solitary Adam was placed in the garden of Eden, God himself declared that it was “not good that the man should be alone” (Gen 2:18). Up to this point in time, this was the only thing in the whole creation that was “not good”. This means that man can only truly understand himself as a finite embodied being in the context of relationships.

It also means that we do not make decisions independently of those around us. Even if we do not care about others, our actions will nonetheless affect them. Moreover, as human persons with a history, we each have a ‘story’ that is inextricably linked to the ‘story’ of others. Whether we realize it or not, we cannot act without being influenced both by our own narrative and by the narratives of others. We may like to think about issues like reproduction in an abstract or individualistic way, but biblically informed Christians will always accept that our choices profoundly affect others.[32] Our freedom, therefore, must be guided and limited by what the Bible says it means to be truly free—part of which is to live in loving relationship with others.

As mentioned, after the sin and judgement of the Fall in Genesis 3, humanity retains God’s image and likeness, passed down from father to son (Gen 5:1, 3; 9:6; also see Jas 3:9). Of course, sin has corrupted the image. That is why those in Christ “have put on the new self, which is being renewed in knowledge after the image of its creator” (Col 3:10). One day this renewal will be complete (Rom 8:29), but not this side of glory (Phil 3:12-14). Nevertheless it is because we retain God’s image, even in our fallenness, that the book of Genesis informs us that shedding human blood is judged with capital punishment:

“Whoever sheds the blood of man,

by man shall his blood be shed,

for God made man in his own image.” (Gen 9:6)

This somber warning, together with other parts of Scripture, tells us how seriously God views murder. For example:

  • Such a crime is not only against man but against God himself, in whose image man is made (Gen 9:6).
  • The murderer himself is liable to be killed and is not protected by the sixth commandment, which prohibits the taking of innocent life (Exod 20:13).
  • The judicial code for retributive justice (i.e. the ‘eye for an eye’ of Exodus 21:24 and Leviticus 24:20) is clarified and qualified elsewhere in the Scriptures, with manslaughter specifically distinguished from murder (Num 35:10-28).
  • Murder pollutes the land in which it is committed, and atonement can only be made by shedding the blood of the one who has committed it (Num 35:33).

As far as God is concerned, the taking of human life is a very serious crime.

Continuity before and after birth

But when does human life begin?

It is quite clear that it does not begin at birth. The Bible indicates that all human beings have a relationship with God while still in the womb. Several passages attest to God’s careful moulding of the human form, while not identifying exactly when this relationship begins:

For you formed my inward parts;

you knitted me together in my mother’s womb.

I praise you, for I am fearfully and wonderfully made.

Wonderful are your works;

my soul knows it very well.

My frame was not hidden from you,

when I was being made in secret,

intricately woven in the depths of the earth.

Your eyes saw my unformed substance;

in your book were written, every one of them,

the days that were formed for me,

when as yet there was none of them. (Ps 139:13-16)

The psalmist, David, uses a variety of words here to evoke the picture of God as a craftsman: “formed”, “knitted”, “made”, “woven”. All of these point to the fact that each human being is a carefully modelled masterpiece. Furthermore, the passage does not refer to the fully developed fetus so much as to the early embryo. This is clear from David’s use of the Hebrew word golem (translated “unformed substance” in verse 16), a term used in Jewish literature to denote the first stage of human life after conception.[33] David Jones associates the idea of our being created in the “depths of the earth” with Adam’s creation from “dust from the ground” in Genesis 2:7.[34] Whether or not this link is present in David’s mind as he writes the psalm, Psalm 139 clearly portrays the mystery of human development long before the availability of antenatal ultrasound. It is also clear that David identifies with his unborn self in his mother’s womb. He is in no doubt that life outside the womb is a continuation of the life that began inside, and he acknowledges God’s full knowledge of his future even as he knows his past (cf. Ps 139:1-10; Heb 4:13). Similar ideas are found in several apocryphal texts (e.g. Wisdom 7:1-4; 2 Maccabees 7:22-23) and also in Job’s words:

“Your hands fashioned and made me,

and now you have destroyed me altogether.

Remember that you have made me like clay;

and will you return me to the dust?

Did you not pour me out like milk

and curdle me like cheese?

You clothed me with skin and flesh,

and knit me together with bones and sinews.

You have granted me life and steadfast love,

and your care has preserved my spirit.” (Job 10:8-12)

Further status is given to the developing embryo in Exodus 21:22-25. This passage outlines the penalties for injuring a pregnant woman during a fight, and appears to give the unborn human equivalent importance to one who has been born:

“When men strive together and hit a pregnant woman, so that her children come out, but there is no harm, the one who hit her shall surely be fined, as the woman’s husband shall impose on him, and he shall pay as the judges determine. But if there is harm, then you shall pay life for life, eye for eye, tooth for tooth, hand for hand, foot for foot, burn for burn, wound for wound, stripe for stripe.” (Exod 21:22-25)

This passage seems to be saying that if men who are fighting injure a pregnant woman and she gives birth prematurely to a live child, the offender is to be fined. But if there is serious injury and miscarriage, you are to take life for life (the life of the unborn child is equated to the life of the attacker). This reading of the Hebrew is reflected in the NIV and ESV translations, among many others. However, consider another translation:

If men struggle with each other and strike a woman with child so that she gives birth prematurely, yet there is no injury, he shall surely be fined as the woman’s husband may demand of him; and he shall pay as the judges decide. But if there is any further injury, then you shall appoint as a penalty life for life, eye for eye, tooth for tooth, hand for hand, foot for foot, burn for burn, wound for wound, bruise for bruise. (Exod 21:22-25 NASB)

If this translation is correct, then a different interpretation follows. The attacker is not to be executed for bringing about the death of the child, but only for bringing about the death of the mother. In other words, it is the mother’s life that is equated with that of the attacker, not the child’s. This could be understood as suggesting that “the unborn do not have the same value or rights as those born”.[35] This is the common Jewish reading of the text, and is also reflected in a number of English Bible translations (notably KJV, NEB and RSV).[36] However, since the death of a (non-pregnant) woman has already been dealt with earlier in the chapter, it’s hard to see why it would be mentioned again.

Much of the confusion surrounding the interpretation of Exodus 21:22-23 stems from the influence of the Septuagint (or LXX).[37] The Septuagint version of the text yields a different translation again:

And if two men are fighting and strike a pregnant woman and her infant departs not fully formed, he shall be forced to pay a fine: according to whatever the woman’s husband shall lay upon him, he shall give with what is fitting. But if it is fully formed, he shall give life for life… (Exod 21:22-25, LXX)

According to this version, the death of a “formed” infant demands “life for life”, but the death of a “not fully formed” infant only warrants a fine. Many early Christians read this version of the Old Testament, and its influence lasted well into the Middle Ages. However, at this point, the Septuagint badly mistranslates the original Hebrew, using the word ‘form’ where the Hebrew clearly means ‘harm’ or ‘injury’. In other words, the formed/unformed distinction is nowhere present in the Hebrew text. In fact this distinction derives from the ancient Greek philosopher Aristotle, whose (incorrect) explanations of early human development were widely accepted at the time.[38]

That the writer of Exodus is making a distinction between an unharmed child and an injured child is clear from his use of the term yeled—the normal term for a child. If the writer had wished to signify the miscarriage of an undeveloped fetus, he could have used the term sakal (the normal word for a miscarriage; cf. Exod 23:26) and referred to the fetus by either golem or nefel.[39] But this is not what is said, nor what is meant. The Hebrew word used is yatsa, which is a more general verb meaning ‘to come out’. In the context of pregnancy this nearly always refers to giving birth (as in Gen 25:24-26 and 38:28-30). Consequently, in the ancient world the Exodus text was not seen as a justification for abortion except, in rabbinic interpretation, to save the mother’s life.

However, the Septuagint was used as a basis for the ‘Old Latin’ version of the Bible (the Vulgate). This in turn was used by Augustine (among others), who felt obliged to embrace a formed/unformed duality. The popularity of his commentaries kept that version of Exodus 21:22-25 alive.[40] Yet it did not change people’s thinking that deliberate destruction of an unborn child was wrong. Indeed Augustine himself “disapproved of the abortion of both the vivified and unvivified fetus, but distinguished between the two”.[41] As I’ve argued, this distinction is based on a misunderstanding of Exodus 21:22-25. But however you interpret it, this passage only refers to accidental injury. Therefore, it “cannot be used to imply support for the intentional destruction of human life in abortion”.[42]

Furthermore, despite an acknowledged lack of understanding of the process involved in embryological development (see Eccl 11:5), the link between conception and birth was clearly understood in biblical times:

Adam knew Eve his wife, and she conceived and bore Cain… (Gen 4:1)

The birth of Christ was similarly announced:

…an angel of the Lord appeared to him in a dream, saying, “Joseph, son of David, do not fear to take Mary as your wife, for that which is conceived in her is from the Holy Spirit. She will bear a son, and you shall call his name Jesus, for he will save his people from their sins.” (Matt 1:20-21)

Indeed, a strong argument for the importance of the nascent human comes from the incarnation of Jesus. It is clear from the Gospels that Jesus’ human existence commenced at his conception. This was certainly the understanding of the early Christian church.[43] As John the Baptist’s prenatal life is similarly described, Jesus’ prenatal life cannot be attributed to his divinity. If Jesus assumed human nature at the point of conception, it follows that all human existence commences at conception.

Luke’s account of the meeting between Mary and Elizabeth in Luke 1 is interesting in this regard. Mary had just been visited by the angel Gabriel, and was in early pregnancy when she hurried to visit her relative Elizabeth, who was 6 months pregnant with John the Baptist:

And when Elizabeth heard the greeting of Mary, the baby leaped in her womb. And Elizabeth was filled with the Holy Spirit, and she exclaimed with a loud cry, “Blessed are you among women, and blessed is the fruit of your womb! And why is this granted to me that the mother of my Lord should come to me? For behold, when the sound of your greeting came to my ears, the baby in my womb leaped for joy.” (Luke 1:41-44)

Luke is suggesting that Jesus and John, both in utero, were as present as Mary and Elizabeth at this meeting: John the Baptist is noted to have ‘recognized’ Jesus. Furthermore, the Greek word brephos, used to describe the unborn John, is the same word used later on to describe the baby Jesus (Luke 2:12) and also the little children who came to Jesus in Luke 18:15.

Luke’s account is also interesting because if Mary went to visit as soon as she received the news (“with haste”, v. 39), and given a journey of approximately one week, Jesus would have been a blastocyst (a 5-7 day old embryo) at the time Mary met Elizabeth, who acknowledged him as her Lord (v. 43).[44]

Pulling the above biblical strands together, then, we can only conclude that God recognizes and interacts with embryonic humans from the time of conception through to birth and beyond.

There are Christians who have argued against this understanding. RJ Berry, an ecological geneticist awarded for his advocacy of the Christian faith in the world of science, argues that Psalm 139 cannot be used to argue for continuity except in retrospect by a rational being (i.e. ‘Since I know I am here now, I realize it was me in my mother’s womb’). He argues it is not legitimate to say that God is in relationship with every fetus and embryo created (including those lost early in development). He makes a point of saying that continuity can only apply to persons:

Once a person exists [which Berry seems to define as one who is able to reason], one must reckon with his or her whole life history as a linked sequence of divinely guided and appointed processes and events. But Psalm 139 says nothing whatsoever about those who are not ‘persons’.[45]

Berry says that if we are honest, we should admit that we don’t know what relationship God has with the early embryo.

In other words, if I say that Psalm 139 seems to show God clearly interacting with a human person in utero, Berry would respond by saying we can’t know that, because by his definition of ‘person’ (derived from elsewhere) the fetus or embryo in Psalm 139 is not a person. This just seems to be an a priori ruling out of inconvenient evidence.

Berry also says we can’t count the incarnation of Jesus because that was a special case. This is a question of who has the burden of proof. Is it those who continue the teaching of the moral worth of the unborn, which extends since Old Testament times, or those who now want to disregard embryonic humans for the sake of scientific research?

Sadly, it appears that the late Anglican theologian Gordon Dunstan was influential in persuading Bishop Harries—the Chair of the House of Lords Select Committee on Stem Cell Research in the United Kingdom—to allow destructive research on embryos in that country.[46] Dunstan appealed to Christian tradition to downgrade the importance of the human embryo. He pointed out in a 1984 article that medieval Christians such as Aquinas believed the embryo did not have a soul until it was fully formed. He claimed it was only since the late 19th century that Christians had given absolute protection to the human embryo “from the moment of conception”.[47] Unfortunately, he based his ideas on the inaccurate translation of Exodus 21:22-23 in the Septuagint, and on the outdated embryology of Aristotle.


How does the Bible suggest we treat this being who is “fearfully and wonderfully made” (Ps 139:14)? We will discuss the Christian ethical framework in chapter 5, but for now I simply want to point out that our God has a special concern for the vulnerable in society, and his expectation is that we will be likewise concerned. He upholds the cause of the weak and oppressed. He shows no partiality, and neither should we (e.g. Deut 10:17-18; 24:14; Isa 1:17). While these passages obviously don’t refer to embryonic human life, is there any member of society more vulnerable than an unwanted human embryo?

Should we give a human embryo the same moral status as a human adult? As we’ve seen, that depends on our view of human personhood. However, even if you are unsure whether the early embryo has the same moral status as a fully developed human adult, this is very different from saying that it has no moral status whatsoever, and is not entitled to any protection or any respect. (Specific exceptions are discussed throughout this book.)

It seems to me that logic obliges us to contend that human life and human personhood begin at fertilization. This is our experience. At no point during my pregnancies did I think of the child I was carrying as an embryo or a fetus. They were always babies, and I think this is a very normal and common perception.

We are now able to see why the public debate regarding when life begins has been so heated and protracted. Issues including the destruction of human life and the potential cure of disabling disease will inevitably arouse emotion. But it is obvious to me that consensus will never be reached, because of the different ways in which those on either side of the debate are addressing the question. Proponents of embryo and fetal destruction are looking at the favourable consequences they expect to result. Opponents will not permit this destruction of human life on any terms, despite anticipated consequences. For those who hold them, absolute moral values will stand regardless of the context.

This may make those opposed to destructive embryo research, for example, seem hard and uncaring to our community. It is suggested that such citizens do not care about human suffering, about those who live in hope of a miracle. There is no equivalent visual symbol for embryos as powerful as the disabled men and women, boys and girls who sit patiently in wheelchairs. We do have ‘snowflake children’—those born from donated ‘excess’ embryos left over from IVF. But they are relatively few in number, and it will be years before they can articulate their opposition as coherently as those who support human embryo destruction and sit eye to eye with politicians in parliamentary hearings.

We cannot expect those who do not acknowledge the authority of the Bible to agree with us, especially when Christians do not even agree with one another. We have not always taken the lead we should have when our community was trying to decide how unborn human life was to be treated. We have at times failed to be salt and light to a society seeking moral guidance. Around the time of the Warnock committee’s enquiry, there were many people looking to the church for direction as to how to treat the human embryo. Our failure is summarized in a comment by philosophers Peter Singer and Deane Wells at the time:

The difficulty here is that those upon whom God could most reasonably be expected to have vouchsafed revelation do not all seem to be in possession of the same information.[48]

This is a challenge for our churches. We need to equip Christians with a sufficiently sophisticated biblical understanding of our culture, including modern biotechnology, so that they are able to participate meaningfully in the public discourse that decides what scientific developments are acceptable to our community on moral grounds.

As for the moral status of the embryo, I would suggest that we need to recognize the personhood argument for what it is: pure expediency, designed to justify political decisions that allow the development of medical technologies and procedures that come with the cost of sacrificing early human life. I recognize that the overwhelming majority of those who want these technologies developed do so with good motives. Treatments for debilitating disease; avoidance of suffering; a child of one’s own—these are good things that we all value, and that we should value. However, we need to ask whether we should seek these things at the cost of another human’s life.

  1. Although we can be confident that (at least most of) the frozen excess embryos are not dead (a permanent state from which one does not return to life—biblical examples excluded, of course), can we say that a frozen embryo—being in a state of suspended animation—is actually alive, or do we have to wait until they are thawed to give them this status? If the latter, we would have to say that the embryos in question are neither alive nor dead. 
  2. Editorial, ‘A question of tolerance’, Times, 24 April 1990. 
  3. O O’Donovan, Begotten or Made?, OUP, Oxford, 1984, pp. 50-7. 
  4. To understand how some Christians came to support legal abortion, see DA Jones, The Soul of the Embryo, Continuum, London, 2004, chapter 13.  
  5. More detailed analysis of Fletcher’s theory is found in Jones, ibid., chapter 14. 
  6. See ‘Marketing strategies’ under ‘3. Understanding different contraceptives’ in chapter 6. 
  7. Roe v. Wade (1973) 410 US 113 at 163. 
  8. P Singer, Rethinking Life and Death, St Martin’s Griffin, New York, 1994, p. 190. Later in the book, Singer suggests that a period of 28 days should be allowed to lapse before the child has a right to life, during which time the parents could decide whether they want the baby. If not then infanticide is, according to his view, morally permissible. 
  9. MO Steinfels, ‘In vitro fertilization: “ethically acceptable” research’, Hastings Center Report, vol. 9, no. 3, June 1979, pp. 5-8. 
  10. Department of Health and Social Security, Report of the Committee of Inquiry into Human Fertilisation and Embryology, M Warnock (Chairman), London, 1984, paragraph 11.22. 
  11. For further explanation of why these markers where chosen, see chapter 2. 
  12. See ‘Human development’ in chapter 2. 
  13. Department of Health, Review of the Human Fertilisation and Embryology Act: A Public Consultation, London, 2005. 
  14. National Institutes of Health, Report of the Human Embryo Research Panel, 1994; American Society for Reproductive Medicine, Ethical Considerations of Reproductive Technology, 1986, 1990 and 1994; National Bioethics Advisory Commission, 1997, 1999; The President’s Council on Bioethics, 2002, 2004. 
  15. Legislation Review Committee, Review of the Prohibition of Human Cloning Act 2002 and the Research Involving Human Embryos Act 2002, Justice John Lockhart (Chairman), Canberra, 2005 (known as the Lockhart review). 
  16. For further discussion of the philosophical approaches to justification of embryo research, see M Suttie, ‘Embryo research and the fourteen day rule: What implications does this global bioethical and legal standard have for human dignity?’, paper presented to the Global Bioethics: Emerging Challenges Facing Human Dignity conference, Chicago, 13-22 July 2009. 
  17. Incidentally, this should remind us of the need to voice our concerns with public policy at the time it is being discussed and decided. In the current public debates in Western society it is regularly pointed out that Christians did not strongly oppose the embryo destruction associated with the introduction of IVF—thus implying that we should not start making a fuss now. 
  18. For refutation of this argument, see ‘3. The problem of wastage’ under ‘Common objections to the argument that human life begins at fertilization’ in chapter 2. 
  19. Department of Health and Social Security, op. cit., paragraph 11.17. 
  20. ‘The Nuremberg Code (1947)’, British Medical Journal, vol. 313, no. 7070, 7 December 1996, p. 1448. 
  21. World Medical Association, Declaration of Helsinki: Ethical principles for medical research involving human subjects, 6th revision, adopted by the 18th WMA General Assembly, Helsinki, 1964 and amended by the 59th WMA General Assembly, Seoul, 2008, paragraph 6. 
  22. Council of Europe, Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine, Oviedo, 1997. 
  23. Australia, Parliament, Human Embryo Experimentation in Australia, Report of the Senate Select Committee on the Human Embryo Experimentation Bill 1985, Parl. Paper 437, Canberra, September 1986, p. xiv. 
  24. FA Chervenak, LB McCullough and A Kurjak, ‘An essential clinical ethical concept’, in FA Chervenak and A Kurjak (eds), The Fetus as a Patient, Parthenon, New York, 1996, pp. 1-9. 
  25. GER Lloyd (ed.), J Chadwick and WN Mann (trans.), Hippocratic Writings, Penguin, London, 1978, p. 67. 
  26. LR Kass, ‘The Repugnance of Wisdom’, in LR Kass and JQ Wilson, The Ethics of Human Cloning, AEI Press, Washington DC, 1998, p. 19. 
  27. ibid., p. 18. 
  28. ibid., p. 19. 
  29. Ethical decision-making is explained in more detail in chapter 5. 
  30. M Hill, The How and Why of Love, Matthias Media, Sydney, 2002; JRW Stott, Issues Facing Christians Today, 4th edn, Zondervan, Grand Rapids, 2006. These texts are recommended for those who would like to explore further ethical issues from a biblical perspective. John Wyatt has provided an expansion of Stott’s scheme in the context of modern biology in his book Matters of Life and Death, 2nd edn, IVP, Leicester, 2009, pp. 51-82. 
  31. This idea is implied by biblical references to divinely ordained vocation (e.g Jer 1:5). For exploration of this theme, see O’Donovan, loc. cit. 
  32. Modern ‘science fiction’ examples used to debate the moral status of the embryo (these will be known to those familiar with the philosophical debate regarding abortion, violinists, etc.) are invalid on these grounds. 
  33. The term is used by JRR Tolkien in The Lord of the Rings to denote the creature Gollum, who is ‘deformed’ by the malignant influence of the ring. 
  34. Jones, op. cit., p. 7. I recommend this book for those who would like to further examine the Christian tradition regarding the moral status of the human embryo. It has informed much of this discussion. 
  35. DP O’Mathuna, ‘Bodily Injuries, Murder, Manslaughter’ in Dictionary of the Old Testament: Pentateuch, TD Alexander and DW Baker (eds), IVP, Downers Grove, 2003, p. 93. 
  36. It is noteworthy that these three biblical translations belong to the same ‘family’ and therefore share much in common. 
  37. The Septuagint, or LXX, is a Greek translation of the Old Testament that was begun by the third century BC and completed sometime before 132 BC. It was used by Greek-speaking Jews throughout the Mediterranean world, and also by the early Christians. 
  38. I have come across the suggestion that the LXX was never meant to be a faithful translation so much as a culturally relevant interpretation of the Hebrew for Greeks at that time. See Mark Scott, ‘Quickening in the Common Law: The legal precedent Roe attempted and failed to use,’ Michigan Law and Policy Review, vol. 1, 1996, p. 204. 
  39. The one place in the Old Testament where the Hebrew word golem is used is in Psalm 139:16. And as we’ve already seen, it is certainly not used there in a way that implies the fetus is less than fully human. Nefel is the usual word for a stillborn child (Job 3:16; Ps 58:8; Eccl 6:3). 
  40. The idea of delayed ensoulment developed from the embracing of Aristotle’s science. Delayed ensoulment is not a biblical idea. Aristotle believed that formation of the human embryo was not complete until 40 days for males and 90 days for females. He believed that the embryo did not belong to the human species, and therefore obtain a soul, until then. Augustine picked up these ideas and they were subsequently propagated by Thomas Aquinas. Aristotle’s embryology was accepted as fact until the 17th century. However, by then both Calvin and Luther had taught that the soul was given at conception. With Aristotle’s biology discredited, Catholic theologians increasingly came to agree. See Jones, op. cit., chapter 4. 
  41. JC Bauerschmidt, ‘Abortion’, in AD Fitzgerald (ed.) Augustine Through the Ages, Eerdmans, Grand Rapids, 1999, p. 1. 
  42. O’Mathuna, op. cit., p. 94. 
  43. Jones, op. cit., p. 129. 
  44. JJ Davis, ‘The status of the human embryo: religious issues’, plenary session at the Genetic and Reproductive Ethics Conference, The Center for Bioethics and Human Dignity, Deerfield, 14-16 July 2005. 
  45. RJ Berry, God and the Biologist, Apollos, Leicester, 1996, p. 73. 
  46. DA Jones, ‘Dunstan, the embryo and Christian tradition’, Triple Helix, Summer 2005, pp. 10-11. 
  47. GR Dunstan, ‘The moral status of the human embryo: a tradition recalled’, Journal of Medical Ethics, vol. 10, no. 1, March 1984, p. 43. 
  48. P Singer and D Wells, ‘In vitro fertilisation: The major issues’, Journal of Medical Ethics, vol. 9, no. 4, December 1983, p. 193. 

Human relationships

In the previous chapter, we looked to the Genesis account to understand what it means to be human. We can see that we are dependent, embodied creatures who are designed to live within the limits set for us by our loving creator God. This is central to the Christian understanding of freedom. Even though when we have children we are ‘co-creators’ with God, we are unlike God in that we are not omniscient, and so even as co-creators we are to continue to observe the limits he has put in place. We are not to take on the role of God for ourselves.

Moreover, as relational creatures, we need to understand what is permissible for us in the context of our relationships. We do not make our decisions in an isolated or abstract way, but as embodied creatures who have a history and experience of life and who live in relationship with others. The aim of this chapter, then, is to understand from the Bible what our relationships are intended to be, and what our responsibilities are within them. Only then will we be able to make ethical decisions that are aligned with God’s will.

When talking about the birth of children, for example, what is the best word to use? Bioethicist Leon Kass underlines the importance of this point when he writes:

Consider the views of life and the world reflected in the following different expressions to describe the process of generating new life. Ancient Israel, impressed with the phenomenon of the transmission of life from father to son, used a word we translate as “begetting” or “siring” [meaning creating the same moral value as the begetter]. The Greeks, impressed with the springing forth of new life… called it genesis, from a root meaning “to come into being”… The premodern Christian English-speaking world, impressed with the world as given by a Creator, used the term “pro-creation”. We, impressed with the machine and the gross national product (our own work of creation), employ a metaphor of the factory, “re-production”.[1]

It can be terrifying to see how easily we can slip into the thought patterns of the world, and how the language we use can lead us unconsciously to embrace a non-Christian world view.

Let us see now what is distinctive about the biblical teaching on the subject of marriage and family.

What is marriage?

In most cultures, marriage is a legal institution. In the West it has traditionally been regarded as a voluntary lifelong union between one man and one woman. Understandably, the state has an interest in marriage as the domestic unit where children are born and raised, thereby renewing society. While the community understanding of marriage has been weakened in recent years, it is still usually seen as a mutually supportive and sexually exclusive relationship.

Although it has come down to us through English common law, this understanding of marriage is grounded in the Bible’s teaching that marriage is a binding covenant between a man and a woman, a covenant witnessed by God himself. So Malachi says:

…the Lord was witness between you and the wife of your youth, to whom you have been faithless, though she is your companion and your wife by covenant. (Mal 2:14)

This is why God is so against divorce, for divorce is the breaking of a commitment that should never be broken. For this reason, divorce was carefully regulated in ancient Israel and only permitted under exceptional circumstances (Deut 24:1-4). Jesus is even more restrictive in his teaching, permitting divorce and remarriage only for unfaithfulness (Matt 19:8-9).[2]

Marriage, however, is not merely a secular institution endorsed by God; it is essentially a sacred institution, ordained by God. The origins of marriage predate its legal formalization. Indeed, Genesis 2 reveals that marriage is at the centre of God’s purposes in creating humanity male and female:

Therefore a man shall leave his father and his mother and hold fast to his wife, and they shall become one flesh. (Gen 2:24)

Marriage thus involves leaving one’s family of origin and cleaving to one’s spouse, thereby creating a new family unit that is a new one-flesh entity. The one-flesh state is expressed in sexual intercourse between husband and wife, but it is fundamentally a new creative act of God. This is why Jesus says, “What therefore God has joined together, let not man separate” (Matt 19:6). Consequently, Scripture repeatedly warns that marriage commitments should be guarded carefully (Matt 5:27-32, 19:3-9; Mark 10:2-12; 1 Thess 4:3-6; Heb 13:4).


Does it have to be just one man and one woman? Is monogamy the only divinely sanctioned pattern for marriage?

While it is true that polygamy was practised by godly men in the Old Testament era (such as Jacob and King David), it often led to discord between the wives and their various children: consider Abraham with Sarah and Hagar (Genesis 16), Jacob with Leah and Rachel (Gen 29:31-30:24), and Elkanah with Hannah and Peninnah (1 Sam 1:1-20). Nevertheless, while it was clearly a practice that was tolerated,[3] it was also regulated (Exodus 21:10-11 outlines a husband’s obligations to his first wife when he marries a second).

On the other hand, it is noteworthy that it was first introduced by the evil Lamech (Gen 4:19) and was not God’s plan in the original creation, as he gave Adam only one wife (Gen 2:18-25). Certainly in the New Testament church, it is clear that a man in leadership is to have only one wife (1 Tim 3:2, 12).

Monogamy, then, is God’s ideal.

The place of sexual intercourse

That sexual intercourse is intended for heterosexual marriage is clearly taught in Scripture and is, therefore, a foundational assumption for the argument of this book. The Hebrew word for the act of intercourse (yada) literally means ‘to know’ (Gen 4:1, 17, 25). In the Bible, ‘knowing’ someone involves personal, intimate involvement. The term applies to coitus, where the penis is placed in the vagina, but the Bible does not count it just as a physical act in humans (as compared to animals). It is also the giving of oneself in an act that can lead to the begetting of new life.

Christians recognize two primary purposes of sex in marriage: it is unitive—expressing and strengthening their common love while providing mutual enjoyment (Gen 2:24); and it is procreative—for having children and perpetuating the human race (Gen 1:28). However, different understandings of the connection between these two purposes are at the basis of the difference between Protestant and Roman Catholic views on sexual relations.

Catholic v Protestant doctrine

In his 1968 encyclical, Humanae Vitae (‘Of Human Life’), Pope Paul VI argued that the meaning of sex and marriage lies only in the combination of the unitive and procreative. As we’ve seen, the unitive refers to the strengthening of the bond between the man and woman, and the procreative refers to the production of offspring. The Catholic Church teaches that each and every marital act (i.e. of sexual intercourse) must retain its relationship to the procreation of human life.[4] In other words, marital sex that only has unitive intention is improper.[5] This is one of the reasons the Catholic Church forbids most contraception.

Protestant churches, on the other hand, teach that the unitive and procreative aspects of marital sex should apply to the overall marriage relationship, but not necessarily to each individual act of intercourse. The Protestant understanding is that the prevention of fertilization through contraception is permissible, as long as the marriage is open to procreation at some time unless serious considerations exclude it.[6] The views put forward in this book will be Protestant unless otherwise indicated.

The nature of the ‘one flesh’ union

Given that sexual intimacy is intended for heterosexual marriage, what more might be said about the ‘one flesh’ union and the purposes of sex in marriage? As we’ve already seen, the language of two becoming “one flesh” (Gen 2:24) is a powerful and evocative way of combining notions of kinship with sexual intimacy, whilst at the same time highlighting a number of the other God-given purposes of marriage. These are listed below.

1. Purposeful companionship

As a gift of God, married love is a good, in and of itself. More than that, it is an expression of our creation in the image of the God who does not exist in solitude, but is a ‘being in relation’, a ‘trinity’ of three persons within one godhead. Marriage is thus intended to provide intimate companionship for image-bearers who are wired for relationship. Not surprisingly, this is the first purpose of marriage mentioned in the Bible. As God himself declares: “It is not good that the man should be alone; I will make him a helper fit for him” (Gen 2:18). However, as Christopher Ash notes:

…we must not conclude that the final goal of this delightful and intimate companionship is to be found in the delight, the intimacy or the companionship. This is delight with a shared purpose, intimacy with a common goal, and companionship in a task beyond the boundaries of the couple themselves.[7]

Relationship and task go hand in hand.

2. Equality and partnership

In creating Eve as a “fit” helper, God is affirming her equal status as a bearer of his image despite her different sexuality. The Hebrew word for ‘helper’ (ezer) underscores this, as most of its uses in the Old Testament refer to God (Israel’s ‘helper’ in times of trouble). Therefore, as Carolyn C James notes, the traditional translation of this word as ‘helpmeet’, and its restriction (in English) to marriage, has led to a diminished understanding of its meaning and application to marriage.[8] The term is a strong one, which contains no suggestion of inferiority. Rather, it implies Eve’s necessity (for Adam needs her), and emphasizes the fact that husband and wife together are to exercise dominion and labour alongside each other to advance God’s kingdom.

3. Differentiated unity

Because he has created Eve directly, God ‘gives away the bride’ at the first marriage. When he presents Eve to Adam, Adam responds ecstatically, describing her as “bone of my bones and flesh of my flesh” (Gen 2:23). This highlights the unity of the man and the woman, a unity that is expressed most fully in marriage. Indeed, the image of shared flesh and the subsequent statement about the ‘one flesh’ nature of the marriage union (Gen 2:23-24) point to the intimacy of this unity when it takes sexual expression. However, it is important to appreciate that it is a differentiated unity. This is captured in the Hebrew word translated as “fit for him” (kenegdo) in verse 18 (literally, ‘like opposite him’), which suggests “both likeness and difference or complementarity”.[9]

4. Ordered complementarity

The unity of the man and the woman is also an ordered unity. This is seen in the fact that Adam was formed first (cf. 1 Tim 2:13), that Eve was taken from him and made for him (cf. 1 Cor 11:8-9), and finally in the fact that Eve was named by him (Gen 3:20). This order, far from undermining the equality of husband and wife, serves and enhances their unity. This is seen most powerfully in Ephesians 5, where the image of human marriage given in Genesis 2 (in both its unity and order) is shown to be a prototype of the union between Christ and his church, his body and bride (Eph 5:22-33). Despite the strain that has come upon all human marriages as a consequence of the Fall (Gen 3:16b), the Ephesians passage shows us that a profound solidarity between spouses, which embraces their different roles and responsibilities, is still God’s intention.[10]

5. Relational priority

Another facet of Genesis 2:24 is that the union of man and woman in marriage takes priority over responsibilities to parents. This is seen in the fact that the man leaves his family of origin to create not an extension of his family, but a new and distinct “public social unit”.[11] This idea is conveyed by the Hebrew word for ‘flesh’ (basar), which is often used of a clan or family group (e.g. Gen 29:14, 37:27). This does not mean that family connections are severed or that the command to honour one’s parents has no further application to those who are married. But it does mean that the responsibilities of husband and wife to each other take precedence over all other relational obligations.

6. Permanence and exclusivity

A clear implication of this relational priority is the fact that the relationship of husband and wife is to be lifelong and exclusive. In other words, in two becoming one flesh we see God’s intention for marriage to be both monogamous and inviolable. In commenting on Genesis 2:24, John Murray says that as for divorce so for polygamy: “from the beginning it was not so… The indissolubility of the bond of marriage and the principle of monogamy are inherent in the verse”.[12] This is why God condemns adultery (Exod 20:14; Lev 20:10) and is so against divorce (Mal 2:13-16). The ultimate theological reason for this understanding is to be found in the model of Christ and the church (Eph 5:22-33). Christ has only one bride, whom he regards as his “body” (v. 30), and he literally loves her to death (v. 25)!

7. Mutual enjoyment and enrichment

The shared intimacy of sex allows for the expression of love that strengthens the bond of the couple. Before the Fall (Gen 2:25), Adam and Eve share physical intimacy without shame. This changes after the Fall (Gen 3:7), although the enjoyment of sexual union and its ability to enrich marriage relationships persists. Passages such as Proverbs 5:18-19 and the Song of Solomon describe the delight the husband and wife should find in each other:

Let your fountain be blessed,

and rejoice in the wife of your youth,

a lovely deer, a graceful doe.

Let her breasts fill you at all times with delight;

be intoxicated always in her love. (Prov 5:18-19)

This combination of mutual pleasure and marriage enrichment is another purpose of human sexual expression within the one flesh union of marriage.

8. Mutual satisfaction and protection

A further purpose of sex within marriage, which we learn from the New Testament, is to suppress the temptation to be sexually immoral:

Do not deprive one another, except perhaps by agreement for a limited time, that you may devote yourselves to prayer; but then come together again, so that Satan may not tempt you because of your lack of self-control. (1 Cor 7:5)[13]

Therefore, as Christopher Ash notes:

In marriage there is a mutual moral obligation on both husband and wife each to surrender their body to the other in willing sexual relations sustained so far as health permits over the lifetime of their marriage.[14]

Of course, the duty to provide each other with mutual sexual satisfaction is not only a defense against unfaithfulness but also protects and nourishes the “one flesh” union. This in turn benefits not only the couple and their children, but also their neighbours and wider human society.[15]

9. The birth of children

Finally, the procreation of children is expected within marriage as a result of sexual intercourse. Indeed, “the intrinsic structure of the act between the man and the woman is intended and designed towards this end”.[16] For as husband and wife come together, so may their gametes (the sperm and egg) result in a child for whom both are responsible. Children, then, are an intended part of the blessing of marriage, and are themselves a rich blessing from God. As the psalmist writes:

Behold, children are a heritage from the Lord,

the fruit of the womb a reward.

Like arrows in the hand of a warrior

are the children of one’s youth.

Blessed is the man

who fills his quiver with them! (Ps 127:3-5a)

Procreation, then, is a good gift of God and a vital part of the divine intention for the “one flesh” union of marriage.

The blessing of children

While the words of Genesis 1:28—“Be fruitful and multiply and fill the earth and subdue it”—are often described as a command, not only are they preceded by a statement of blessing (“And God blessed them”), but the Hebrew is also suggestive of a blessing.[17] Nor does this blessing disappear after the Fall, for it is repeated to Noah and his family following the flood (Gen 9:1, 7). Obviously (and for many, painfully), not all couples are able to have children—a reality that is repeatedly acknowledged in Scripture.[18] Nevertheless, children within marriage are presented as the norm, for it is through the birth of children that the image of God is perpetuated (Gen 5:1), and the creative and redemptive purposes of God achieved.

However, it also needs to be said that the life-partnership of marriage should not be seen as subservient to the procreation and training of children. Karl Barth notes the Roman Catholic teaching (derived from Thomas Aquinas)[19] that it is subservient, and insists the opposite is true. Barth’s view is that the family is subordinate to the marriage, the life-partnership, which does not depend on the coexistence of children to be valid. This would seem to be supported by Genesis 2:18-22, which contains no explicit mention of children and where the emphasis falls on the relationship between the man and the woman. But this point should not be overstated, for the ‘command’ to multiply has already been supplied in Genesis 1 and Scripture nowhere encourages ‘chosen childlessness’.[20] Marriage as a loving life-partnership is indeed a highly significant work in itself, and one that mirrors the union of Christ and the church. And so it is a valid end in itself.[21] Nevertheless, marriage, as the basic unit of society, is the God-ordained context within which the raising of children occurs.[22]

Ironically, the blessing of children was not experienced by Adam and Eve prior to the Fall. Furthermore, following the Fall, the experience of childbirth becomes a difficult one for Eve; the Lord God says to her, “I will surely multiply your pain in childbearing; in pain you shall bring forth children” (Gen 3:16). In addition to this, the task of filling the earth has also become more difficult, for mortality has entered the scene. So Adam is told that he will return to dust (v. 19).

Nevertheless, God’s creative and redemptive purposes will prevail. For, although Adam and Eve have been barred from access to the tree of life (Gen 3:22-24), “Immortality is replaced by progeny, opening the door to redemptive history”.[23] Adam subsequently calls the woman ‘Eve’—mother of all the living (v. 20), trusting the Lord’s promise that she will bear offspring who will finally defeat Satan. For this reason, parenthood is closely related to the salvation story. So the Scriptures trace the children of the promise from Eve’s seed or offspring (Gen 3:15), through the line of Abraham, all the way to Jesus (Matt 1:1-16), God’s Son, who was “born of woman” (Gal 4:4), and then through Jesus to all who have received his Spirit (Gal 4:5-6, 28)—a multiethnic multitude that no-one can number (Rev 7:9).

For those who take the time to go looking for them, there are a lot of creative lists on the internet explaining why people should have children. In my experience the usual reasons include things like:

  • to continue the family line
  • to look after you when you’re old
  • for self-fulfilment
  • as a physical representation of your “one flesh”
  • to help in the family business.

There is no doubt that the desire to have children can be strong, and we should sympathize with those who are unable to fulfil it. We can even understand why people in our community talk about a ‘right to reproduce’ and seek ever-expanding technologies to achieve it (Prov 13:12). However, the Bible teaches us to view children rather differently.

Christians see child-bearing not as a way to find self-fulfilment so much as to raise up “Godly offspring” (Mal 2:15). A new generation must learn how to exert responsible dominion over the creation, and while we are waiting for Christ to return we are called to proclaim the gospel. Therefore, we will do better to consider our responsibilities rather than our rights. The Bible does not suggest we possess our children, but that we receive them as a gift:

“Behold, children are a gift of the Lord;

the fruit of the womb is a reward.” (Ps 127:3, NASB)

The responsibilities of parenthood

The Bible speaks of parenthood not just in terms of procreation but also in terms of the subsequent time, effort and love involved in childrearing, regardless of the child’s biological origins. The honour of parenthood is lifelong and to be lived out according to God’s commands. When a child is biologically related to its parents, this relationship usually begins before the birth. The responsibilities of parenthood remain for both parents even if they are not married, although this situation will inevitably be more difficult.

Parents are to stand as a witness and a godly example to their children. This seems to be part of the reason the apostle Paul regards the children of even just one believing parent as “holy” (1 Cor 7:14). Such children are not only acceptable to God (rather than being “unclean”), but also stand in a place of privilege. Consequently, they will be “marked by an element of shaping and ‘difference’ from a wholly pagan environment”.[24] This does not mean they are born Christians, or that they will inevitably become Christians, but that there is a saving and sanctifying influence adults can have over their children merely by the fact of their existence and presence as Christians.

Parents are called to nurture their children. God expected Abraham to “command his children and his household after him to keep the way of the Lord by doing righteousness and justice” (Gen 18:19). With regard to the Law, God’s words, Moses instructed Israel to “teach them diligently to your children… talk of them when you sit in your house, and when you walk by the way, and when you lie down, and when you rise” (Deut 6:7). In Proverbs, children are repeatedly exhorted to heed the wisdom of their parents (e.g. 1:8).

In teaching their children about the ways of God, parents are also expected to exercise authority over their children—not in a domineering way, but by modelling their own obedience to God and discipling the children on his behalf. Ephesians 3:14-15 tells us that God is the Father from whom all fatherhood is named. Our children are his children. Any way we can serve our children, he can surpass, whether it be in giving good gifts (Matt 7:9-11) or administering discipline (Heb 12:7-11).[25] Therefore, we must model our parenting on his. This is why the New Testament says to fathers: “do not provoke your children to anger, but bring them up in the discipline and instruction of the Lord” (Eph 6:4). Similarly, “do not provoke your children, lest they become discouraged” (Col 3:21).

This latter teaching, that fathers should be careful to avoid overburdening their children and arousing rebellion, reminds us how important it is to operate in a framework of grace. Christian parents, no less than their children, stand in constant need of the mercies of God. The extended contact they have with their children provides a unique opportunity to communicate this, for the time God gives them. The end must come, either with the child returning to God or with the child leaving his or her parents. Then the cycle will begin again (1 Tim 5:4).

If the gracious love of God is the reason he “makes his sun rise on the evil and on the good, and sends rain on the just and on the unjust” (Matt 5:45), so we must seek to lovingly provide the things that our children need regardless of their response (1 John 3:11-16).

These needs will include the material. Responsibilities to our families in this regard will be ongoing. In 1 Timothy 5:8, Paul tells us that “if anyone does not provide for his relatives, and especially for members of his household, he has denied the faith and is worse than an unbeliever”. Parents should be aware of whether the needs of each child are being met, and this will include being responsible stewards when they reach the point at which their resources cannot provide for additional children.

We also know that a sense of belonging is important for children. In the Old Testament we see examples of God encouraging the children of Israel to remember the stories of his deliverance (such as with the memorial stones in Joshua 4:4-7, 20-24), which belong to the generations. Furthermore, as embodied, finite creatures, we are all linked by lines of kinship and have a place in time and space. Our very existence is, in one way or another, embedded in a family line. This is easy to forget at times in our individualistic society.

But does this have to be within a nuclear family?

Other definitions of ‘family’

A nuclear family consists of a married couple and their children. There has been public pressure in recent years to broaden the definition of ‘family’ to reflect what is happening in our society. While there have always been step-families, children raised by grandparents, and other combinations resulting from the vicissitudes of life, the advent of ‘children without sex’ has opened up new ways of becoming parents. Every now and then a single, female Hollywood star decides she can’t wait any longer for a man, and decides to have a child without one. Actress Sharon Stone, single mother of three adopted sons, has said:

I’d urge anyone who is even considering it to go ahead and make their own family, instead of sitting around dreaming and hoping that their Prince Charming is going to come and give them children. What’s the point?… Make it happen for yourself. If your Prince Charming does come, then he’s going to walk in and say, ‘Oh, just what I’ve been looking for, a family waiting for me’. We can do that these days.[26]

Same-sex couples can now ‘reproduce’ with the assistance of donor gametes and ART procedures. Many of the biological barriers to child-bearing in the past no longer apply.

There are numerous examples of family structure in the Bible. The Old Testament features the ancient extended tribal families, while the more urbanized New Testament exhibits a pattern of households (which often included servants). The modern Middle Eastern experience of family is still quite different from the experience of family known to most Westerners. None are identified as being superior. However, married couples remain central within all these models, along with the expectation that their relationship is permanent and exclusive.

Interestingly, Jesus taught us that it is our brothers and sisters in Christ who are our true family: “whoever does the will of God, he is my brother and sister and mother” (Mark 3:31-35; cf. Matt 12:46-50; Luke 8:19-21). He also taught that our allegiance to God is more important than family ties (Matt 10:34-38; cf. Luke 12:49-53, 14:26; Mark 10:28-31). However, we know from Genesis that God’s original plan was for a child to be brought up in a home with a male and female parent.

In other words, the biblical norm is for family to proceed from a married couple. Whilst this is not everyone’s experience, there is a significant difference between missing out on this through tragedy or misadventure, and creating an alternative situation on purpose.

How does this influence decisions about procreation?

In a world where we have the options of surrogacy, donor sperm, frozen embryos and genetic testing, how do Christians respond to the God-given desire for a child?

According to the Bible, children are the result of the “one flesh” union between husband and wife, a physical sign of their mutual love. The family is the intended place for the raising of children. Does this mean that married couples have a right to have children? In view of the technology now available to assist with reproduction, do we have a right to pursue a child at all costs?

In answering such questions, several points need to be considered. First, because human beings are creatures under the authority of the creator, we are free to act within the limitations of God’s design. Our God-given drive to procreate is meant to function within that design. We are free to try to carry out the God-given instruction to be fruitful. We are free to pursue healing if our bodies are damaged in some way that makes child-bearing difficult.[27] But not at any cost. We are not to disobey God’s word in our efforts to become parents.

Second, the responsibilities parents have in caring for their offspring will be another limiting factor on what we decide as we go about making reproductive choices. We will aim to witness to a gracious, generous God. We will aim to provide a sense of belonging, whether biological ties exist or not, as our children grow. We will aim to protect our embryonic children from destruction, our fetal children from harm. This does not give us clear ethical guidance in every instance, as all child-bearing involves risk of some kind, both to mother and child. We must pray for wisdom in our decision-making. Yet some things are clear. We will respect human life, its dignity and its value, for each person is made in the image of God throughout the entire procreative process; that is, from fertilization on.

The Bible also talks about our responsibilities to our spouse. In our desire for a child we should not risk our marriage. The stresses of coping with issues of childlessness are well known. Nowhere in the Bible are we promised that every married couple will be able to have children. Nowhere are we promised that if we do have children, they will be healthy. Children are a gift of God, and we are to nurture them in the time they are with us. We will extend to them the same love and hospitality that has been shown to us and is therefore expected of us. Above all, we will stand united with our spouse as we seek to serve our heavenly Father, whether that be as parents or not.


In Western culture (including Western Christian culture), it is now customary for married couples to delay child-bearing while the marital bonds are being strengthened. During this period, husband and wife will be more interested in considering and ensuring contraception than in actively building a family. We therefore need to consider whether it is ethically acceptable for Christians to use contraceptives, and if so, which ones. However, before embarking on this task, we first need to examine a model for ethical Christian decision-making.

  1. LR Kass, Toward a More Natural Science, The Free Press, New York, 1988, p. 48. 
  2. Many commentators conclude that Paul also allows divorce and remarriage for believers who have been deserted by an unbelieving spouse (1 Cor 7:15-16). Historically, this view is given expression in chapter XXIV of The Westminster Confession of Faith (1646), which says, “nothing but adultery, or such willful desertion as can no way be remedied by the Church or civil magistrate, is cause sufficient of dissolving the bond of marriage” (paragraph 6). 
  3. Although the Bible is silent on the reasons for this, there is no question that polygamy enabled the people of Israel to multiply more rapidly (although not all households would have been able to support more than one wife). It also compensated for the high fatality rate amongst men due to the brutality of ancient warfare, which would have often meant that there were more women than men in Israelite society. Added to that, as it was difficult for an unmarried woman to provide for herself, there were clearly compassionate reasons for tolerating the practice of polygamy. There is debate as to whether the law of the Levi (Deut 25:5-10) commands a married man whose brother has died to marry his wife and give her children. Since the law is incomplete (with no mention of what is required if there is no brother, for instance), it is possible there were unwritten assumptions of what was required—for example, that the law referred to the oldest unmarried brother. See C Ash, Marriage: Sex in the Service of God, IVP, Leicester, 2003, p. 251. 
  4. Encyclical of Paul VI, Humanae Vitae: On the Regulation of Birth, Rome, 25 July 1968. 
  5. Pope Paul VI bases his arguments in Humanae Vitae on arguments of natural law, which basically maintains that all created things have a ‘natural’ and presumably divinely intended use (e.g. sex = procreation) that humans can rationally work out. Traditionally Protestants have rejected this line of argument on grounds that, since the Fall, man’s reason has been damaged by sin, and it is only through biblical revelation that we can be sure of God’s intended purposes. Paul VI did not refer to Genesis in his encyclical. 
  6. Karl Barth notes the need to take into account “various considerations regarding… physical and psychological health” that may make it impossible for a couple to assume responsibility for children. See K Barth, ‘Parents and Children’, in Church Dogmatics, vol. III.4, GW Bromiley and TF Torrance (eds), T and T Clark, London and New York, 2010, pp. 272-3. This will be discussed further in chapter 6. 
  7. Ash, op. cit., p. 121. 
  8. CC James, Lost Women of the Bible. Zondervan, Grand Rapids, 2005, pp. 335-6. 
  9. A Perriman, Speaking of Women, Apollos, Leicester, 1998, p. 180. 
  10. Ephesians 5 also confirms that order in marriage (i.e. headship and submission) is not a consequence of the curse. The Fall distorted the God-given order, but it did not create it. True headship means love and self-sacrifice (Eph 5:25), and true submission is not a matter of enforced subservience but of voluntary service and respect (Eph 5:33). 
  11. Ash, op. cit., p. 348. 
  12. J Murray, Principles of Conduct, Eerdmans, Grand Rapids, 1957, p. 30. 
  13. See also 1 Thessalonians 4:3-4. 
  14. Ash, op. cit., p. 190. 
  15. ibid., p. 110. 
  16. ibid., p. 248. 
  17. BK Waltke and CJ Fredricks, Genesis: A commentary, Zondervan, Grand Rapids, 2001, p. 67. 
  18. I will address the issue of childlessness in chapter 10. 
  19. Thomas Aquinas, Summa Theologica, 2nd edn, trans. the Fathers of the English Dominican Province, Part III, Burns Oates and Washbourne, London, 1926, p. 39. 
  20. As we have already noted, there are sometimes good and valid reasons (of a medical or psychological or even financial kind) that require some couples to choose (albeit reluctantly) not to have (more) children. See further in Ash, op. cit., pp. 175-9. 
  21. Barth, op. cit., p. 258. 
  22. See chapter 6 for discussion of the altered nature of this command under the New Covenant. 
  23. Waltke and Fredricks, op. cit., p. 94. 
  24. A Thiselton, The First Epistle to the Corinthians, Eerdmans, Grand Rapids, 2000, p. 530. 
  25. Barth reconciles the teaching regarding discipline in Proverbs (3:11-12, 13:24, 19:18, 22:15, 23:13-14, 29:15) with Hebrews 12 by explaining that the task of parents since the coming of Jesus is to teach their children not the law but the gospel. See Barth, op. cit., p. 271. 
  26. M Freedman, ‘Women are looking for standing ovation as curtains threaten to close on fertility’, Sun-Herald, 16 March 2008, p. 28. 
  27. See chapter 16. 

Which ethical basis?

In a pluralist society it is difficult to find moral consensus, because we no longer have a common process for working out right from wrong. We hope our legislators will consider an ethical perspective as they make decisions, but there is no guarantee that their ethics will be consistent with biblical ethics.

Let me illustrate some common ways of making ethical decisions in our community by using the example of abortion.

The most common approach to deciding right from wrong in our society is to judge actions solely by their consequences—that is, the rightness or otherwise of a course of action is determined by looking at the outcome. As I mentioned briefly in chapter 3, this ethical theory is called consequentialism. If you expect a good outcome, then it is a morally good decision. If you anticipate a bad outcome, it is the wrong ethical choice. For example, a consequentialist finds that she has an unplanned pregnancy. She worries that this unwanted baby will have a bad effect on her health, her career, and her general happiness. She reasons that since an abortion would remove these threats to her future and provide a better outcome, then an abortion is the ethically correct choice for her.

Another popular theory involves evaluating choices in terms of an individual’s rights. In the case of abortion, we often hear the classic argument of a woman’s ‘right to choose’ what happens to her body. While there are some recognized lists of rights (such as The Universal Declaration of Human Rights by the United Nations),[1] nowadays many people use ‘rights’ language simply to demand something they really, really want, but which is not actually a valid ‘right’ at all.

In many heated public debates on topics such as abortion, you often hear an argument like this: “If you don’t like abortion then don’t have one, but don’t stop someone else from having one”. This argument is based on a theory called moral relativism. According to this theory, there is no absolute right or wrong, and moral rules are just an expression of personal preferences (influenced by cultural factors). Therefore choosing an abortion is a matter of expressing your personal preferences and values, and does not need any other reason to justify it—just as if you were choosing what to eat for breakfast. Furthermore, no-one should judge another’s choice and ask for abortion to be banned.[2]

Sometimes the ethically correct healthcare for an individual is decided by what is best for the community as a whole—a theory called communitarianism. Consider, for example, when public policy needs to determine what public funds will be spent on, or which procedures will be legal. Some people justify abortion for disabled babies on the grounds that it is better for the community if disabled children are not born, so that they don’t have to be supported, which costs society time and money. Note that you would need to combine another theory with this one, because the main feature of communitarianism is its assumption that what is right for the individual can be determined by working out what is best for the group. (Christian responses to all these arguments are given below.)

Cuts both ways

Note that each of these common ethical theories could also be used to argue against abortion. The consequentialist might decide that missing out on being a mother is a bad outcome, so she may decide against abortion. The rights advocate might consider the right of the baby to life. The relativist might just prefer not to have the abortion, and the communitarian might decide it is bad for the community to allow the devaluing of human life, and decide that abortion is wrong on these grounds. The ethical theory you use is just an instrument that gives you a method to work through the question; it does not necessarily determine what you decide. Your presuppositions (the basic principles that you accept as true—such as believing that life starts at fertilization) will also make a big difference to your conclusion. This demonstrates that, even without using biblical principles, non-Christians will at times agree with Christians on issues of morality, though possibly for different reasons.

Christian decision-making

Serious ethical deliberation involves a logical process of working through basic principles to determine what is the right thing to do. Human reason therefore plays a role in evangelical ethics, but a Christian will not operate without the guiding authority of Scripture. However, because human reason is fallible, and because we don’t all have exactly the same priorities or the same perceptions of the way the world is, it is possible that two Christians will approach the same ethical question and come to different, but valid, conclusions. They would not come to a conclusion that is contrary to Scripture, but there are many issues on which Scripture is silent. For example, given that government is operating under God’s authority (as Romans 13 teaches), what mode of government is correct? While we would probably all prefer democratic government on grounds of human equality, some of us might support a more capitalist version of democracy because it encourages human enterprise, and others might favour a more socialist version because it aims to support the poor and the weak.[3] Both conclusions make sense. That is why there are Christians in different political parties.

In order to make informed and biblical decisions, we really need two things: a clear understanding of the facts related to the decision, and a sound biblical framework for making sense of them and working out what is the right and wrong thing to do. In medical decision-making, many Christians often struggle with the first of these factors—that is, they simply don’t have a good knowledge of the facts, often because of rapidly changing technologies that are emerging. Much of the rest of this book will be concerned with providing this information.

However, knowing the facts is not enough. We also need a clear and applicable biblical foundation on which to base our decision-making. In this chapter, I will introduce one basic approach, but there are excellent accounts elsewhere which provide comprehensive explanations.[4]

All explanations of evangelical Christian decision-making will use the Bible as the moral compass. The Bible contains some specific guidance—for example, we are told to obey God’s commands as an expression of our love for him (John 14:15). We also find some general moral principles in its pages that we can confidently follow (e.g. Matthew 5-7). However, just as important is the Bible’s portrayal of the character of the God we seek to emulate—his goodness, justice, mercy, grace and forgiveness (Exod 34:6-7). There are also numerous lists of the qualities of character (virtues) that we should seek to develop as we grow in godliness (Gal 5:22-23; Eph 4:1-3, 32; Phil 4:8; Col 3:12-13; 1 Tim 4:12, 6:11; 2 Tim 2:22, 3:10-11; Titus 3:1-2; 1 Pet 3:8; 2 Pet 1:5-7). Furthermore, the Bible teaches us the context of our lives—what we are as human beings, what kind of world we live in, and what lies in our future.

As we already began to see in chapter 3, it is also important to consider the whole of Scripture as it unfolds so that our conclusions are not distorted by a partial appreciation of God’s purposes. This will involve reflecting on what is often called ‘biblical theology’—the framework of God’s unfolding revelation in the Bible:

  1. Creation: the world as God originally made it
  2. Fall: the world as it is affected by sin
  3. Redemption: the world in light of salvation through Christ
  4. Future consummation: the world in view of the glorious future awaiting us

So, for example, with regard to the principles for moral behaviour given to Israel in the Old Testament, we need to remember that the biblical revelation is progressive, and that these principles will need to be interpreted in light of the New Testament. Paul tells us in Romans that we are no longer under the law—in fact, we are delivered from the law (Rom 6:14, 7:6)—and so we will look carefully at the validity of Old Testament ethical instruction, using it as a source of Christian wisdom rather than a strict code of law.[5]

As Hill points out, many of the New Testament virtues are related to personal relationship and community—virtues like compassion, kindness, hospitality, gentleness, generosity, peaceableness, truthfulness, humility, patience and forbearance.[6] This reminds us that we are creatures made for relationship, which will be an important consideration in all our decision-making.

So how do we put it all together? Below is a framework that can help us combine the important considerations for any decision and check whether we are indeed following biblical principles.

A model of ethical decision-making for Christians

In any moral choice, we are first moved to act by our motivation, which leads to an intention to achieve a certain goal. We then take action to achieve that goal, and our action will have certain consequences. How does the Bible judge the importance of each of these components of our ethical choice?

We begin by recognizing that we face an ethical decision, and developing the motivation to respond. This will determine not what we are going to do so much as why we are going to do it. Christian motivation is grounded in the summary of the commandments given by Jesus in Matthew 22:37-40: “Love the Lord your God with all your heart and with all your soul and with all your mind” and “love your neighbour as yourself”. For example, if a Christian (let’s call him Tom) sees a woman suffering from unrelieved pain, he will be moved by love and compassion to want to help.

Once we have been motivated to act, we consider what we want to achieve. This is our intention. We begin to consider a particular goal, which will help us to decide on an appropriate course of action. Mind you, good intentions are not enough on their own. Good intentions do not justify wrong actions (as Paul insists in Romans 3:8); nor are good intentions an excuse for doing nothing (as James reminds us in James 2:16). However, if we have bad intentions, this can be as bad as having performed a wrong action (Matt 5:21-22, 27-28).

Both intentions and actions are significant. Jesus told us that our actions are a reflection of what is in our hearts and minds (Mark 7:21-23). We therefore will see some overlap between our intentions and our actions.

To take our example to the next step: having been motivated to help, Tom now decides to try to stop the woman’s suffering by relieving her pain. He has formed an intention, but what action will he take?

In recent times, some people advocate euthanasia—that is, killing those who are in pain and suffering, in the (usually erroneous) belief that it is the only way to stop their pain. However, Tom is aware that there is a biblical prohibition on killing people (Gen 9:6; Exod 20:13; cf. Matt 5:21-22), so he rules out that course of action. The action itself is wrong, even if the intention is noble or good (in this case, compassion for the suffering person). Compassion moves us to act, but does not inform the content of our actions.

Tom decides to give the woman medication to stop the pain. This is a compassionate response that does not violate any biblical principles.

The last aspect of our choice involves examining the consequences of our action. Consequences are important, and we do need to consider them. However, we cannot decide right from wrong by looking at consequences only. There are a few reasons for this. We might remember, firstly, that the end does not justify the means (there are some things we should never do regardless of the consequences, as Romans 3:7-8 makes clear). Moreover, God knows our hearts and minds, and he is concerned by our motivation and intention as well as our actions and their consequences (cf. Matt 5:27-28). Besides, consequences are enormously difficult to predict and to assess—even after the fact, let alone in advance. So in the case of euthanasia, there is on the one hand the consequence of a sick person’s suffering being eased. But on the other hand, there is the distinct possibility that allowing euthanasia will certainly lead to some people being killed against their real wishes. How do we weigh these consequences against one another, let alone all the other possible outcomes and consequences? And can we do so credibly in advance, when we simply cannot predict or control what will eventuate? Consequences alone are an inadequate basis for ethical decision-making.

However, we do need to consider what effect our actions will have, for good or ill. Now, before we go any further, we need to acknowledge that all things are in our sovereign God’s hands, and that we cannot foresee all consequences. God knows this, and we are judged according to those things for which we are responsible, not those things that are out of our control. God’s judgement will be just (Rom 3:19). We should aim for a good outcome, but if a bad outcome intervenes through circumstances beyond our control, we are not morally liable.

That said, Christians will judge consequences in light of gospel values. If we are aiming to love our neighbours and do what is best for them, we will look for outcomes in which suffering is eased, loving relationships are fostered, justice is done, and so on (see Mic 6:8). Sometimes we will need to be creative in considering what options are available to us. Sometimes we will have to choose an option that has a difficult and personally costly outcome. Sometimes we will be surprised by the way God works to bring good out of evil (Rom 8:28). But God has promised that we will never be forced to submit to the ethically wrong but easy way out when we are tempted to give way (1 Cor 10:13). We also need to remember that we cannot control the actions of others, and that we must expect to see troubles in this fallen world (John 16:33).

To return to our example: the consequence of Tom’s action is that the woman’s pain is relieved and her suffering eased. He considers this a satisfactory result by biblical standards.

MOTIVATION Love for God and for our neighbours. Christian character is developed according to the virtues listed in the New Testament.
INTENTION Both intentions and actions should be obedient to God’s word and keep in mind the nature of the creation.
CONSEQUENCES Will be measured according to God’s standards for justice; we will be concerned for the vulnerable, we will be merciful and we will keep in view the future consummation.

Note that to maintain a Christian ethic in decision-making, the following is necessary:

  • study of the Scriptures to identify relevant themes and rules
  • development of Christian character (put on virtues, take off vices)
  • development of a Christian world view by making it our practice to think things through in a gospel context and collecting any extra information we need
  • prayer that God’s spirit will give us wisdom and the power to change.

A retrieval ethic

Sometimes we find ourselves having to choose between two ‘evils’. As Michael Hill acknowledges, the tensions of living in a fallen world mean that love for God and for our neighbours cannot always be sustained as we would like. At these times, we will find that the Bible permits a retrieval ethic—an allowance from God in view of the hardness of our hearts. To justify this approach Hill looks to passages like 1 Corinthians 7:10-16, where God, who hates divorce, will allow it when mutual love cannot be accomplished, as a way of salvaging what good is possible and minimizing harm (cf. Matt 19:8).[7] Sometimes all we can do is try to minimize the damage that results from actions we cannot control.

This needs to be carefully evaluated. A retrieval ethic is not based on a different system of morality to that I have described. Rather, “the same value system [is] operating in two different ways”.[8] As Hill describes it, good and evil remain constant, but where sin has limited the opportunity to act as we would wish, some goods may need to be abandoned and others taken up. His example refers to divorce, where the oneness of marriage is no longer possible if one party leaves the relationship for an adulterous union. However, a cordial relationship may be able to be maintained through legal separation and formal divorce. This is particularly helpful if children are involved.

Decision-making in medical matters

It is difficult to make choices if we are not sure what it is we are choosing between. As mentioned above, one of the challenges of decision-making in bioethics is that we need to understand something of the science before we can start talking about ethics. Christians have at times been discredited for speaking out on scientific issues about which they were ignorant.

I am not saying we shouldn’t speak out until we know every single detail. But we will be taken more seriously in public debate if we know our facts and we know our limitations. This is a challenge for our churches, but we need to trust that God will provide people, if not in our own congregations then in our geographical areas, who can educate us about current controversial bioethical issues.

Responding to alternative ethical theories

At the beginning of the chapter we looked at several ethical theories that are popular in modern society. Having looked at the Bible’s ethical framework, how might Christians respond to these alternative approaches?

Let us start with consequentialism. While the Bible teaches that we should consider the consequences of our actions, it does not support the idea that consequences are the only things that matter, or that consequences should overrule all other considerations. We would therefore reject the argument that a good outcome (such as the mother’s emotional or financial or career wellbeing) justifies abortion on grounds that killing an unborn child is an unjust and immoral action in itself. The mother’s desire to secure her future wellbeing does not justify taking human life any more than, say, inheriting a valuable property justifies killing your parents.

Regarding rights theory, we will be more interested in loving our neighbours than in asserting our rights over them (1 Cor 10:24). We would also point out that the proliferation of ‘rights’ (usually self-claimed) results in impossible conflicts. So, for example, if I have a right to personal happiness or prosperity, what happens when my neighbour’s right to the same thing conflicts with mine? Whose right should have priority? Likewise, why does a woman’s right to control her own body override a baby’s right to life and liberty? In the end, these conflicts are usually resolved by the more powerful trampling on the rights of the weak. The mother decides that the baby’s right to life is not morally relevant or not as important as her right to happiness, and so aborts the baby. And the baby is in no position to stop her.

Moral relativism is often regarded as ‘politically correct’, and necessary for maintaining community harmony. But while it may appear to promote tolerance, insisting that all moral positions are personal and relative is both illogical and impractical. It is illogical because moral relativism is itself claiming to be the correct ethical theory. And it is impractical because no-one ever sticks to it. You don’t have to push a moral relativist very far before they admit that some things are universally good or evil (whether it is racism or sexism or child abuse or whatever). Also, by reducing the abortion argument to ‘Don’t have an abortion if you don’t approve’, moral relativists are avoiding the question of right and wrong entirely and confusing it with personal preference. But for those opposed to abortion, personal preferences are beside the point when you are fighting for an absolute moral value such as the protection of innocent human lives. And personal preferences certainly shouldn’t be the basis for the law that provides the moral standard for a whole society.

With regard to communitarianism, we will always consider the needs and welfare of those around us, and will desire to build strong and loving communities. But working out what is best for a community will depend on one’s vision of the good life, and what constitutes the ‘best’. So whereas supporters of abortion would argue that it is better to abort disabled babies so that the community does not have to bear the cost of supporting them throughout their lives, Christians would say that this is not only a morally wrong action in itself, but is also based on a morally defective view of what makes a good community. In a truly good community, everyone would be treated with love, dignity and respect, not dispensed with if they are weak or disabled or become expensive to care for.

Christians do support communitarianism in that we believe there are absolute moral truths that are the good gift of the God who made the world, and that upholding and living out these truths will be for the benefit of everyone in the community.

For doctors

Medicine has for some time focused on the ‘four principles’ approach to healthcare ethics developed by Tom Beauchamp and James Childress (often called ‘principlism’).[9] The principles they identified as important in this context were:

  1. Beneficence (the obligation to provide overall benefits to patients when balanced with risks)
  2. Non-maleficence (the obligation to avoid causing harm)
  3. Respect for autonomy (the obligation to allow mentally competent patients to make decisions on matters that affect them)
  4. Justice (the obligation to treat patients fairly regarding benefits and risks)

However, the authors never intended this framework to be used as an independent ethical theory. Beauchamp recommended it be used “together with other moral considerations”.[10] In fact, it is extremely difficult to decide what to do using only these four principles.

For one thing, it does not tell you whose autonomy ought to be respected if more than one patient is involved. If you were deciding whether abortion was the right or wrong thing to do, you may consider going ahead if you wanted to respect the autonomy of the woman requesting one. But what of the unborn child whose autonomy is being radically terminated? Moreover, you are denying the unborn child justice by intentionally killing it—an act that can only be described as harmful (maleficent). From this perspective it would be the wrong thing to do. Obviously, further principles are required to work out what to do in this situation. If we consider the principles with regard to the mother, abortion is the right thing to do. If we look at it from the baby’s perspective, it isn’t.

Furthermore, the way the principles are used in medical practice usually makes them a form of consequentialism (deciding right from wrong only on the basis of the consequences of an action). That is, beneficent actions are determined as those with good outcomes; maleficent actions are determined as those with harmful outcomes; and so on. As such, the ‘four principles’ approach suffers from the problems and inconsistencies that all consequentialist moral theories share. We know from Scripture that we are not to decide right from wrong purely by consequences—the end does not justify the means. We need to consider the morality of motive, intentions and actions as well, as we have discussed above. The ‘four principles’ approach will be inadequate on its own to assess morality for Christians.

The usefulness of the principles lies in reminding us that we should aim to do good and not harm, to take into consideration our patients’ wishes where appropriate, and to treat them justly. This is not the complete list of our obligations, but it is a start.

Doctors interested in engaging with medical ethics would do well to do further reading about ethical theories. This will put you in a position not only to formulate and understand your own ethical approach, but also to be able to analyse and interact with the arguments of others. Beauchamp is right when he says that “it is insupportably optimistic to think we will ever attain a fully specified system of norms for health care ethics”.[11] There is no longer sufficient societal consensus for this to happen. I agree with Pellegrino that the most likely candidate to allow development of a unique ‘professional medical ethic’ is virtue theory (which looks at the preferred virtues, or qualities of character, of a good doctor). His writing on this topic is recommended. [12] This style of approach is becoming loosely categorized as ‘Hippocratic medicine’, and you could do a lot worse than aim for that.

Now that we have covered the basics of biology, theology and ethics, we will look at specific areas of the beginning of life that need to be evaluated from a Christian perspective. We will start with contraception.

  1. UN General Assembly, The Universal Declaration of Human Rights, 10 December 1948. 
  2. For a comprehensive refutation of moral relativism in the abortion debate, see F Beckwith, Defending Life, Cambridge University Press, New York, 2007, chapter 1. 
  3. This example is taken from J Stott, New Issues Facing Christians Today, rev. edn, HarperCollins, London, 1999, p. 46. 
  4. For a detailed explanation of ethical Christian decision-making, see M Hill, The How and Why of Love, Matthias Media, Sydney, 2002. 
  5. For further discussion of the place of Old Testament laws in Christian ethics, see A Cameron, Joined-up Life, IVP, Nottingham, 2011, pp. 135-40. 
  6. Hill, op. cit., p. 38. 
  7. Hill, ibid., pp. 132-4. 
  8. ibid, p. 133. 
  9. TL Beauchamp and JF Childress, Principles of Biomedical Ethics, 3rd edn, Oxford University Press, New York, 1989. 
  10. TL Beauchamp, ‘The “four principles” approach’ in R Gillon (ed.), Principles of Health Care Ethics, Wiley, Chichester, 1994, pp. 3-12. 
  11. Beauchamp, op. cit., p. 12. 
  12. ED Pellegrino, The Philosophy of Medicine Reborn, University of Notre Dame Press, Indiana, 2008, chapter 12. 


The current generation of fertile adults has not known a time when contraception was not safe and easily available. As a result, they have grown up with the unquestioned belief that was expressed with the arrival of the oral contraceptive pill: you can have ‘sex without reproduction’.

But is this really true? Has there really been a rupturing of the link between sex and pregnancy? The abortion rate would seem to indicate not. While unwanted pregnancy does not account for all cases of abortion performed annually in Australia (as opposed to abortion where the pregnancy poses a threat to the mother’s life, for example), it certainly accounts for most of them. In fact, one of the factors that drove the demand for accessible abortion was the belief that it was no longer necessary to accept pregnancy as an inevitable consequence of being sexually active. But regardless of what our society would like to think, the reality is that fertile couples who engage in sexual relations will always have a chance of becoming pregnant.

Yet the myth that sex is no longer connected to child-bearing persists, and the thought that there might be ethical objections to the use of contraceptives in marriage does not occur to many Protestant couples. We may take time to consider which form of contraception we should use, but very few couples pause to consider whether they should use it at all. We are used to the worldly idea that we can control our child-bearing just as we can control (at least, we like to think so) most other areas of our lives. It is interesting to note, however, that contraception was opposed by Protestants from the time of Luther right through until 1930, when the first institutional moves towards its acceptance occurred. Even today, many churches (most notably the Roman Catholic Church) reject most forms of artificial contraception.

Is it morally permissible for married Christian couples to use contraceptives? There are at least two important ethical questions to be answered:

  • Is it ever morally permissible for Christians to use contraception?
  • If so, are there any particular methods of contraception that should be avoided?

This chapter will look at both of these questions. I apologize in advance that doing so will take some time—but the issues are complex and have a long history. The chapter falls into three parts:

1. A brief history of contraception, which looks at how views towards contraception have developed and changed in Christian history (depending on level of interest, some readers may wish to skip this section).

2. A theology of contraception, which looks at the Bible’s teaching on whether it is morally permissible for Christians to use contraceptives.

3. Understanding different contraceptives, which looks at the wide range of contraceptives available, and at the moral implications of using each of them.

In all of this, my intention is not to make anyone feel guilty for past choices. I would like to encourage you to think about this subject prayerfully, and use the information given to inform your future choices.

1. A brief history of contraception

There are ancient Egyptian records dating from between 1900 and 1100 BC providing recipes for women to avoid pregnancy. Formulas include ingredients such as crocodile dung, honey, acacia tips and dates, which were smeared around the vulva or placed in the uterus in an attempt to prevent sperm from entering the uterus.[1] Ingredients like sodium carbonate appear in recipes for contraceptives in European literature, so it is likely that some of this knowledge persisted to Christian times. We can be confident that the withdrawal technique was known amongst the Hebrews by the story of Onan (Gen 38:8-10). The Talmud contains references not only to this technique, but also to pessaries, sterilizing potions and sterilizing surgery. Ancient Graeco-Roman society was educated by Aristotle’s History of Animals and Pliny’s Natural History. Although these writers were more interested in the underlying science, they did give instructions for contraception. By the second century AD, the Greek gynaecologist Soranus of Ephesus wrote about the association between ovulation and fertility, and promoted a flawed version of the rhythm method. He also gave information on potions and pessaries, as well as a rather less scientific method of contraception which involved the woman getting up after sex, squatting, and sneezing loudly to dislodge the sperm! (Don’t try that one at home.) Some of his contemporaries recommended an ointment to be applied to male genitals (possibly as a spermicide), and amulets (perhaps suggesting, if magic was worth a try, that none of the known contraceptives were particularly reliable). Soranus’ book, Gynecology, was the most important guide to contraception not only during the time of the Roman Empire but also, through the Arabs, throughout medieval Europe.

There is no doubt that knowledge of contraceptive techniques existed in biblical times. Use of them, however, was not thought to be common in Israel due to the value placed on child-bearing in the Old Testament. God blesses humanity in Genesis 1:28, and commands the man and woman to “Be fruitful and multiply”. This instruction is repeated after the flood (Gen 9:1), and in Deuteronomy, Israel is told that God “will love you, bless you, and multiply you. He will also bless the fruit of your womb… There shall not be male or female barren among you” (Deut 7:13-14). (See further biblical references to contraception below.)

While the use of contraceptive methods is not thought to have been widespread amongst the Hebrews, there is no doubt that it was widespread amongst the Romans. Although sexual immorality was rampant in the late Roman Empire, so was childlessness and declining birth—so much so that laws were introduced to ban contraceptives in an attempt to increase the population size.[2] It is unlikely that the Jews or the New Testament Christians would have been ignorant of such a prevalent social phenomenon.

Philo (20 BC-50 AD) was the earliest Jewish philosopher to discuss contraception, and he is thought to provide an example of Jewish thought on marriage at the time of Jesus. He was influenced by the Stoics, an austere school of Greek philosophy. The Stoics mistrusted emotion and tried to control bodily desires by rational thinking. They were more interested in justice than in love. Marriage based on passion, therefore, was suspect. According to Stoic beliefs, there must be another reason for marriage, and plainly that was reproduction. While Philo rejected the Stoic elimination of all emotion, he nonetheless regards overly strong desire for one’s spouse as a source of wickedness: “Now even natural pleasure is often greatly to blame when the craving for it is immoderate and insatiable… as the passionate desire for women shown by those who in their rage for sexual intercourse behave unchastely, not with the wives of others, but with their own”.[3] From other writings, it seems that ‘behaving unchastely’ refers to having sexual intercourse for pleasure. He interprets the Old Testament as teaching that God blesses married couples who have intercourse specifically for children, such as Abraham and Sarah, and curses those who don’t, such as Onan, who used Tamar without impregnating her (Genesis 38). His writings influenced a number of second-century Church Fathers.[4]

Noonan comments that the development of Christian doctrine is usually a response by the Christian community both to meditation on Scripture and to the pressures of the environment.[5] Further development of an early Christian doctrine of contraception is thought to have been a reaction to the two most influential attitudes in the Greco-Roman world—the Gnostics and the secular pagans.

The Gnostics were a heretical sect within early Christianity who regarded the physical world as evil and corrupt. For the Gnostics, true spirituality was mystical and non-physical. Accordingly, they believed in total celibacy and condemned marriage as a sinful impediment to true spirituality and godliness, bolstering their arguments by appealing to the example of Jesus. They pointed to those parts of the New Testament (such as 1 Corinthians 7) that teach that singleness and celibacy are valid options for Christians.

Clement of Alexandria (c150-215 AD) argued against the Gnostics that marriage was legitimate, its purpose being procreation. He turned to the law of nature as described by Paul in Romans 2:15 to construct a natural law of marriage, contrasting the natural and purposeful act of procreation with both sexual license and forced abstinence within marriage. He taught that to have sexual intercourse in marriage “other than to procreate children is to do injury to nature”.[6]

Thus ‘nature’ became a key factor in orthodox Christian teaching, and has been the basis for Roman Catholic teaching on sexuality ever since. Interestingly, the early Church Fathers (such as Origen, Clement, Ambrose and Jerome) used the concept of ‘nature’ in three distinct senses. One sense compared sex and the sowing of a field. The idea here was that a pattern discovered in a process uncontaminated by humans was ‘natural’, and so could safely be translated into law for humans. In a second sense, the natural was seen to be what animals do—once again, since human sin was not involved, such activity could be held up as a universal pattern for behaviour. The third sense of ‘natural’ related to what was observed in the human body, particularly the function of different organs—so the fact that ‘eyes are to see with’ told us what was natural to eyes. Such functions were held to be self-evident, requiring no further proof; and they were not necessarily seen in context of the whole body.

In summary, the natural law approach led the early Church Fathers to conclude that sexual desire was evil, as it could lead a man to use his wife for purposes other than procreation. Once you sow the seed, you should wait for the harvest, not keep sowing more seed upon it.[7] While a husband should love his wife, love and sex were seen as separate. This meant that sex for pleasure alone, sex during menstruation, sex during pregnancy, sex in old age and sex with contraception were all evil. Unnatural sexual acts were also condemned.[8]

There were some dissenting voices. In the late third and early fourth centuries, Lactantius and St John Chrysostom defended Paul’s teaching that marriage was not just for parenthood but also to promote sexual purity, implicitly allowing some license for more frequent sexual union in marriage. However, they did not extend their arguments to allow for contraception.[9]

Church opposition to contraceptive use is most strongly influenced by the writings of Augustine of Hippo (354-430 AD). As a young man, Augustine was involved for 11 years with a new religion, Manicheanism, which promoted frequent non-procreative intercourse and abortion. It is thought that Augustine’s teachings on sex and contraception were a direct reaction to his involvement with the Manichees, against whom he wrote two books within a year of his conversion.[10]

Augustine held that the purpose of marriage, and therefore of sexual intercourse within marriage, was procreation. He reasoned that if, as the Bible teaches, man and wife become one flesh in sexual intercourse (Gen 2:24; Matt 19:5; Eph 5:31), then man becomes all flesh in intercourse, which is a threat to his spiritual freedom.[11] Marital sex must therefore have an external purpose to justify this danger (i.e. procreation). Furthermore, in opposition to the heretical teaching of Pelagius,[12] Augustine taught that since original sin was transmitted through sexual generation, sexual desire (which he saw as bad) had to be balanced by the good of possible procreation. Otherwise, sexual relations, even within marriage, were sinful.[13] He opposed contraceptive use even within marriage as morally corrupt, suggesting that it turned matrimonial intercourse into prostitution and the wife into a harlot.[14] He used the story of Onan as an example of judgement for avoiding the propagation of children in marriage.[15] He particularly opposed the method of ‘natural family planning’, which was the contraceptive strategy used by the Manichees. (It is ironic that the main method singled out and condemned by such a prominent church spokesman on sexual matters is the only one allowed by the Catholic Church today.)

Augustine summarized his position by claiming that the goods of marriage are offspring, fidelity and symbolic stability—proles, fides, sacramentum.[16] There is no mention of love between spouses. Procreation was only to be avoided by complete abstinence. And, according to his reading of the Bible, since virginity is preferable to marriage, continence in marriage is also preferable to intercourse.[17] Augustine’s powerful presentation of the case against contraception was hugely influential, and persisted within the Western church for 1000 years.

In the centuries following Augustine, opposition to contraception and sexual pleasure in marriage continued within the church largely unopposed. Pope Gregory ‘the Great’ (pope from 590-604), managed even to ‘out-Augustine’ Augustine not only by limiting married intercourse to the purpose of procreation, but also by condemning any pleasure gained during the exercise. Since most people found it difficult to separate the two, copulation itself became an unavoidably sinful activity. Contraception was unthinkable. Gregory did not consider this policy to be anti-marriage or to be a new doctrine, citing Psalm 51:5 (“in sin did my mother conceive me”).

The monastic movement, which did so much to preserve and pass on Christian teaching during the period from 500-1100, was also staunchly opposed to contraception. The monastic attitude to sexuality and contraception is reflected in their ‘penitentials’—lists of sins, each with prescribed penances. Looking at penitentials written between the sixth and 11th centuries, the contraceptives described are potions drunk by women. While we don’t know how seriously penances were enforced, use of contraception was seen as a serious sin, with penance by fasting for 7-15 years (bread and water only). This indicates the gravity with which contraceptive use was viewed. At the same time, anal or oral intercourse was also regarded as a serious sin, often viewed more seriously than homicide or abortion. (This suggests that control of lust was the key factor, rather than the protection of life.) Coitus interruptus (the withdrawal method) earned a penance of up to 10 years. Intercourse where the woman is on top of the man was rejected on grounds that it impedes procreation (actually untrue) and is ‘doglike’. It received a penance of 40 days (and even more if it was customary behaviour).

The most significant outcome of the penitentials for the doctrine of contraception was the text Si aliquis, which became canon law in the 13th century. Its first expression was as follows: “If someone (Si aliquis) to satisfy his lust or in deliberate hatred does something to a man or woman so that no children be born of him or her, or gives them to drink, so that he cannot generate or she conceive, let it be held as homicide”.[18]

In 1230, Pope Gregory IX directed Dominican monk Raymond of Pennaforte to make a collection of decrees (the Decretals), which was to become Catholic Church law for the next 685 years. Si aliquis was included, with artificial contraception once again being equated with homicide. Along with 6 centuries of sexual behaviour interpreted by the penitentials, this created the mentality that marriage was for procreation, that sexual behaviour beyond the ‘missionary’ position was objectionable, and that contraception was evil.

By this time, the Catholic Church’s opposition to contraception was settled, based on the natural law approach pioneered by Clement, on Augustine’s teachings, on the rules and penances of the monks, on Si aliquis, and on a consistently expressed theology that saw procreation as the only legitimate purpose of marital intercourse.

Thomas Aquinas (1224-1274 AD) provides us with the classical expression of the Catholic view. Highly influenced by the teaching of Augustine, he took Genesis 1:28 to mean that the procreation of children is the primary purpose of marriage. He promoted ‘natural law’, arguing that what is in nature comes from God himself, and that while using contraception may not seem so severe a sin as, say, sins which harm our neighbour, it is still in fact a sin against God.[19] Thomas condemned contraception because it was homicide (it destroyed potential life), it was against nature (by frustrating the aim of intercourse, which was insemination), and it destroyed marital relations (by violating the main/only purpose of marital intercourse). In this presentation, the ban against contraception could rationally be argued as necessary for the good of man. It is noteworthy that in the case of a woman being unable to conceive due to sterility or pregnancy, intercourse was not deemed unnatural. It was not the lack of procreation but the avoidance of depositing semen in the vagina that made the act ‘unnatural’.

Thomas reinforced the norm that became the basic assumption of later writers: heterosexual marital coitus, the man above the woman, with insemination resulting. This is the ‘natural’ act, established by God, deliberate departure from which is an offence against God. The gravity of the offence lies either in the harm done to the potential human life or in the frustration of the normal process of preserving the human race. Thomas also accepted the ideal of married love, and considered it possible to have marital intercourse without sin, as even animals seemed to enjoy sex.

I will not continue the story of the Roman Catholic approach to contraception, except to say that although Augustinian ideas were challenged and sanctions softened, and contraception was no longer viewed as homicide but simply as a violation of the purposes of marriage, contraception remained condemned.

With the arrival of the Reformation, Protestant church leaders such as Martin Luther and John Calvin broke with Roman Catholicism on many subjects. However, on contraception they remained largely in line with Catholic doctrine. Luther largely held to Augustinian teaching on sexuality, as well as emphasizing that children are a blessing from the Lord (Gen 1:28). Calvin argued for three purposes of marriage: companionship (Gen 1:27; 2:18, 21), procreation (Gen 1:28), and the controlled exercise of God-given sexuality (Gen 2:22). He rejected the idea that singleness/celibacy was a superior state to marriage.[20] Both Calvin and Luther opposed contraception on the basis of Genesis 38. Noonan suggests that the Protestants’ holding of the Catholic line encouraged the Catholic Church not to change its position.[21] The Protestant position on contraception remained largely unaddressed until the 19th century. Discussion did not really proceed beyond the condemnation of coitus interruptus on the basis of the story of Onan. Meanwhile, the use of contraceptives quietly spread.

In the late 19th century, in response to lobbying by Protestants, legislation began to be passed in the United States to suppress contraceptive use. Laws such as the Comstock Act, passed in the United States in 1873, prohibited distribution of contraceptives and birth control information (on grounds of it being obscene material). Such laws not only limited access to information about contraception but also created a public perception that contraception was to be equated with pornography (which may explain why the discussion of contraception was often seen as shameful). It was not until 1960 that the United States Supreme Court overturned a law in Connecticut that prohibited the use of contraceptives by married couples.

By the 1920s, the physiology of reproduction was being understood accurately for the first time, and the calendar rhythm method was introduced in 1932. At the same time, the birth control movement grew in the late 19th and early 20th centuries in response to the Comstock laws. Led by Margaret Sanger and Marie Stopes, the movement used arguments about the need to limit population growth in view of available resources,[22] and the need to save poor women from abortion in the event of unplanned pregnancy.[23] The turning point came in 1930 when Anglican bishops at the Lambeth Conference controversially voted to approve limited contraceptive use within marriage—a reversal of the strong opposition voiced ten years previously. The 1930 resolution recognized that there may be moral grounds for restricting parenthood and that limited use of contraceptives was permissible:

Resolution 15: The Life and Witness of the Christian Community—Marriage and Sex

Where there is clearly felt moral obligation to limit or avoid parenthood, the method must be decided on Christian principles. The primary and obvious method is complete abstinence from intercourse (as far as may be necessary) in a life of discipline and self-control lived in the power of the Holy Spirit. Nevertheless in those cases where there is such a clearly felt moral obligation to limit or avoid parenthood, and where there is a morally sound reason for avoiding complete abstinence, the Conference agrees that other methods may be used, provided that this is done in the light of the same Christian principles. The Conference records its strong condemnation of the use of any methods of conception control from motives of selfishness, luxury, or mere convenience.

Voting: For 193; Against 67.[24]

The Roman Catholic Church responded with Casti Connubii (‘On Christian Marriage’), an encyclical written by Pope Pius XI. He reiterated the Augustinian teaching that the goods of marriage were offspring, fidelity and sacrament, with offspring the primary good. God had spoken to all married people when he commanded them to “Increase and multiply, and fill the earth”.[25] He reinforced the ban against contraception, but made an ambiguous comment about the ‘rhythm method’ of birth control, which was seen as a possible endorsement. (The confusion did not clear until 1951, when Pope Pius XII formally approved the rhythm method for all Catholic couples.)

Contraception was formally approved by the United Church of Canada in 1932, the Federal Council of Churches in the United States in 1931, and the Lutheran bishops of Sweden in 1952. In each case it was noted that the decision needed to be made carefully by individual couples according to their consciences and in light of scriptural teaching.[26] Most Protestant denominations have since followed suit.

In the early 1960s, the oral contraceptive pill became available. R Albert Mohler Jr has noted that:

Lacking any substantial theology of marriage, sex, or the family, evangelicals welcomed the development of ‘The Pill’ much as the world celebrated that discovery of penicillin—as one more milestone in the inevitable march of human progress and the conquest of nature.[27]

Protestant contraceptive use continued, unquestioned.

The next Catholic Church pronouncement came in 1968 with Humanae Vitae (‘Of Human Life’), issued by Pope Paul VI. It was expected that he would relax the traditional stand on contraception, in keeping with the recommendations of a papal commission and the spirit of the Second Vatican Council (1962-1965). But it was not to be. He proclaimed that “each and every marital act [of sexual intercourse] must of necessity retain its intrinsic relationship to the procreation of human life”.[28] He pronounced that both the unitive meaning (where the married couple grow in love and companionship) and procreative meaning (where the potential for children is realized) of the sexual act within marriage are to be realized in every sexual act. The traditional opposition to artificial contraception was reiterated.[29]

The motivation for Roman Catholic teaching is understandable: “to experience the gift of married love while respecting the laws of conception is to acknowledge that one is not the master of the sources of life but rather the minister of the design established by the Creator”.[30] However, while wanting to acknowledge God as the one on whom all life depends (Job 1:21), Protestants do not agree with the Catholic view that observing God’s design in nature can be a reliable guide to establishing a theology of marriage and contraception. We derive our beliefs not from observation of nature but through careful reading of Scripture. Furthermore, we would not agree with the implication that contraception is as offensive as abortion, as Humanae Vitae seems to suggest.[31]

The contemporary Protestant view recognizes the validity of sexual intercourse for “completion of marital fellowship” independent of any intention to conceive children.[32] The resolution of the 1930 Lambeth Conference first permitted contraceptive use when chosen according to “Christian principles”.[33] In the discussion of contraception in his multi-volume Church Dogmatics, Protestant theologian Karl Barth argues that the unitive aspect is the “first essential meaning” of sexual intercourse, and that intercourse does not need to be associated with the desire for children.[34] He advises that use of contraception is permissible at times in marriage, but that the decision to use it should be “under the divine command and with a sense of responsibility to God, not out of caprice”.[35] Such “Christian principles” and “divine commands” can only be worked out if we look to the ultimate guide for Christian ethical decision-making: the Bible.

2. A theology of contraception

From our historical overview we can see that the contemporary Protestant position on contraception has not been the prevalent view in the history of Christianity. How has the modern Protestant view been formed? How have we decided that it is permissible for sexual intercourse in marriage to be used for the unitive purpose only?

As we seek the Bible’s guidance on the subject of contraception within marriage, we need to look at its teaching on the purpose of marriage, and the place of sex within marriage.

This teaching begins with the divine command of Genesis 1:28 to Adam and Eve: “Be fruitful and multiply and fill the earth and subdue it”. This command is repeated to Noah and his sons after the flood (Gen 9:1). We can then see it being worked out through the story of Israel. The promise of plentiful offspring was an important part of God’s covenant with Abraham in Genesis 15, and continued through his sons. The Old Testament ends with God’s reminder through Malachi that he desires to see “godly offspring” as a result of marriage (2:15). Indeed, in one sense the whole Old Testament story is a working out of God’s promise in the garden of Eden that, through the descendants of Eve, a saviour will be raised up (Gen 3:15).[36] This promise culminates in the New Testament with the coming of Christ.

The Old Testament considers children to be a blessing:

Behold, children are a heritage from the Lord,

the fruit of the womb a reward.

Like arrows in the hand of a warrior

are the children of one’s youth.

Blessed is the man

who fills his quiver with them! (Ps 127:3-5)

Your wife will be like a fruitful vine

within your house;

your children will be like olive shoots

around your table.

Behold, thus shall the man be blessed

who fears the Lord. (Ps 128:3-4)

Marital intercourse is seen as a duty in the Old Testament:

“If [a man] takes another wife to himself, he shall not diminish her food, her clothing, or her marital rights.” (Exod 21:10)

In the Mishnah (the Rabbinic teachings recorded in the Talmud), Rabbi Eliezer is recorded as saying that the frequency of conjugal duty “for men of independent means was every day, for laborers twice a week, for ass-drivers once a week, for camel-drivers once in thirty days, for sailors once in six months”.[37] According to the Rabbinic school of Shammai, if a man vowed to avoid intercourse with his wife, the period should not be more than two weeks, and according to the school of Hillel it was only one week.[38]

In the New Testament there is less emphasis on procreation, and discussions of marriage include mention of the legitimate place of celibacy. For example, Jesus’ discussion of marriage in Matthew 19:10-12 opens up the possibility that some will choose to make themselves eunuchs (i.e. renounce marriage) for the sake of the kingdom. Paul also identifies chosen celibacy as a gift that allows the receiver to remain free from the troubles of this world, and instead to be concerned with the Lord’s affairs and pleasing him (1 Cor 7:32-35). Some also see Revelation 14:1-5, where John sees 144,000 who have not defiled themselves with women, as being a further commendation of celibacy—although in light of the symbolic nature of Revelation, it is best not to push this verse too far.

While there is little specific teaching in the New Testament on the procreative aspect of marriage and sex, it is very possible that this was simply a given. When Paul commended the mutual duty of marital intercourse (1 Cor 7:2-5), it is unlikely he did not expect children to result—although it is noteworthy that he doesn’t actually mention procreation in the entire passage.

Some have suggested that there is a significant difference between the Old and New Testaments on this issue. Karl Barth, for example, argues that since the coming of Christ, the propagation of the human race as commanded in Genesis 1:28 has ceased to be an unconditional command. The Old Testament necessity to procreate the “holy sequence of generations” has reached its goal in the birth of Jesus. In the Christian community, therefore, heirs do not have the same significance that they did in Israel, because all men are children of God through their spiritual unity with the Son of God (John 3:6). Marriage remains as a valid option for God’s children, but it now represents Christ and his community (Eph 5:22-33; 2 Cor 11:2). This new state of affairs explains why it is no longer shameful to bear no children, or to be unmarried, as all God’s elect are part of Christ’s bride and will be invited to the marriage feast of the Lamb.[39]

Christopher Ash has challenged this view.[40] He notes that the forward-looking character of the Old Testament was focused not only on the Messiah, but also on the building of Israel and the continuance of humanity. He notes that the genealogies do at times follow the Davidic line, but not always (e.g. Genesis 10, 36). He questions the idea that pious Israelites sought offspring through marital intercourse only with the hope of contributing to the genealogy of the Messiah, because this would make the whole ethical underpinning of marital intercourse a kind of ‘procreational lottery’. Besides, Ash adds, if that is the case, there is the irony that the Messiah was eventually conceived without parental intercourse.

Whilst the difference between the Testaments can easily be overstated on this point, the emergence and endorsement of chaste singleness in the New Testament supports the claim that God does not require all humans to reproduce. This establishes the honour of the single person’s vocation. However, it does not clarify what married couples should do. As long as the world lasts, someone has to provide the human generations needed to rule and care for it. But does that mean that all married couples need to have the maximum number of children possible, or, in fact, any children at all?

Even in the Old Testament, there are suggestions that maximal propagation of the human race was never God’s intention. Proverbs 5:18-19, for example, calls upon the husband to delight himself in his wife; and Song of Songs is famous for its celebration of the delights of sexual love. Neither passage mentions children. Marital intercourse is not portrayed in these passages as merely a procreational duty. According to Pope Paul VI in Humanae Vitae, marriage is honoured only when every act of marital intercourse is open to the conception of a child. But Anglican theologian Oliver O’Donovan points out that this claim fails to recognize that sexual intercourse over the course of a marriage has its own cumulative quality, building intimacy in the context of regular physical union during the whole of the life together. The use of contraception does not reduce marital sex to the same level as a series of one-night stands, which the Pope’s view could seem to imply.[41]

Furthermore, we know that not every act of sexual intercourse results in a child. It is not physically possible. God did not make women fertile for the whole of their adult life (unlike other animals). Whilst some couples, sadly, are completely sterile, all couples experience episodes where procreation simply is not possible—for example, during the infertile phase of a woman’s monthly cycle, and after menopause. Even if we were to build our theology of contraception on the observation of nature (as Roman Catholicism does), we would be forced to conclude that while procreation is naturally inherent to the marriage overall, it cannot be so for each and every sexual act.

Nonetheless, it is evident that God encourages child-bearing as the norm in marriage, even if it is not always possible. Apart from the original divine command to be fruitful, God encourages his people to increase in number, even in times of adversity (Jer 29:6). Similarly, in the New Testament widows are encouraged to remarry and have children (1 Tim 5:14). Biblical eschatology doesn’t overturn or contradict the created order. That is, God’s will for married couples in ‘the last days’ is the same as it was in ‘the first days’; they are to be open to having and welcoming children. The burden of proof would seem to rest on anyone who wanted to argue that children are no longer inherent to God’s purposes for marriage.

Some authors have identified prohibitions against specific forms of contraception in verses such as Deuteronomy 23:1, where we are told that “No-one whose testicles are crushed or whose male organ is cut off shall enter the assembly of the Lord”. However, this is more likely a condemnation of corrupt Canaanite religious practices involving castration than a prohibition against male sterilization. Whatever the case, we are no longer bound by such requirements under the new covenant.

Onan has the dubious honour of providing the one explicit example of contraceptive practice in the Bible:

And Judah took a wife for Er his firstborn, and her name was Tamar. But Er, Judah’s firstborn, was wicked in the sight of the Lord, and the Lord put him to death. Then Judah said to Onan, “Go in to your brother’s wife and perform the duty of a brother-in-law to her, and raise up offspring for your brother”. But Onan knew that the offspring would not be his. So whenever he went in to his brother’s wife he would waste the semen on the ground, so as not to give offspring to his brother. And what he did was wicked in the sight of the Lord, and he put him to death also. (Gen 38:6-10)

According to the later Levirate law (Deut 25:5), Onan’s duty was to raise an heir for his deceased brother by having intercourse with his brother’s widow, Tamar. But because the child born from this relationship would not be considered his, he intentionally did not complete the sex act with Tamar to avoid impregnating her. He appeared to accept the obligation placed upon him to marry his sister-in-law, but then failed to carry it through. It was a repeated sin. While this story has often been used in support of a contraceptive ban for Christians, Onan’s subsequent punishment was unlikely to be because he used a contraceptive method.

We have noted above that contraceptives were known and widely used in biblical times. If all contraceptive use was forbidden, we would expect to see it mentioned in the text. However, a passage such as Leviticus 20:10-21, which contains a long list of sexual crimes, contains no mention of a prohibition on contraceptive practices. If use of contraception deserved the death penalty, how much more would we expect it to appear? It is more likely that Onan’s punishment was due to his failure to honour his dead brother and obey God’s command. His motives were sensual and selfish, agreeing to have intercourse but preventing conception so that his own inheritance would not be diminished by the birth of a nephew. Although the penalty for defying the Levirate law in Deuteronomy was public shaming, Onan’s actions were particularly exploitative. He displeased God, and God judged him by putting him to death.

The Bible, then, does not expressly forbid contraception. Does it specifically endorse it? In 1 Corinthians 7, Paul permits abstinence from sex within marriage for spiritual purposes, but only as a temporary and mutually agreed practice:

Do not deprive one another, except perhaps by agreement for a limited time, that you may devote yourselves to prayer; but then come together again, so that Satan may not tempt you because of your lack of self-control. (1 Cor 7:5)

United States theologian John J Davis sees this as implying a larger principle where “Christian couples have the right to choose to ‘override’ the usual responsibility to procreate (Gen 1:28) for a season in order to pursue a spiritual good”.[42] However, considering the restrictions placed on this activity by the apostle (i.e. that this is the exception, not the rule; that it is only for a set time for a specific reason, after which the couple is to come together again; and that it does expose you to moral danger), it is very hard to see that Paul is recommending abstinence in this passage as a regular method of birth control. Indeed, the passage does not even discuss child-bearing, but rather the need to be united sexually in marriage in order to be holy.

In the absence of any scriptural prohibition against contraception, and given that the Bible was written in a world where contraception was well known and widely practised, it would seem that there is a legitimate place for contraception in marriage. If this is the case, when is it acceptable?

The Genesis account of creation, where mankind is commanded to procreate, helps us approach this question. If we consider that humanity is made in the image of God and called to be God’s representatives in the world, we are not only dependent on God, without whose help no child is born (cf. Gen 4:1), but we are also persons who are free to make choices, whether good or bad (Gen 2:16-17; Gal 6:7-8). We have the responsibility to act as good stewards—as parents as well as individuals. As parents, it is not enough just to beget offspring; we are also called to nurture our children as they grow.[43] And we know from our ethical framework that we should seek to have godly motives and perform actions that are consistent with God’s will.

With regard to our motives, as mentioned previously, we should begin sexual relations with the understanding that parenthood may be a consequence (sex without children being a myth). In view of the Bible’s high regard for children, any attempt to avoid their birth must be done with a clear conscience and not for arbitrary or self-interested purposes. If we seek to honour God in all our decision-making, we will be aware that such self-interest is clearly opposed to God’s will. However, even when our motives are right, decisions are not always simple and some situations are clearer than others.

Contraception may have a place in Christian marriage when its purpose is to time the arrival of children. Birth control allows married couples time to strengthen their love and commitment at the beginning of a marriage, before the arrival of children. Care of newborns can be demanding and tiring, and contraception can give the couple time to prepare for parenthood.

Since the responsibilities of parenting extend beyond birth, factors such as temporary financial or ministry restrictions may make timing of the arrival of children an important consideration. In 1 Timothy 5:8, Paul tells us that we are to provide for our relatives and especially our immediate family. This suggests that parents need to be responsible stewards regarding their ability to support children, and be realistic about how many they can effectively provide for. And ‘provision’ includes physical, emotional and spiritual needs. The wellbeing of children already born may require extra time between children to allow for the proper fulfilment of parental responsibilities—especially if, for example, a child is born with a disability. Such decisions should be made prayerfully and jointly between husband and wife, and with an awareness that God may overrule our plans.

Chosen childlessness

A couple may have valid reasons for deciding against having children. In our fallen world, there may be times when a couple may long for the blessing of children, yet sadly see this path as unwise given their particular circumstances. For example, if we view contraception as an expression of permissible medical care for promoting health,[44] it is possible to envisage how it might be used for such a purpose. Some contraindications to child-bearing will be straightforward, if tragic—such as life-threatening complications for the wife if she became pregnant. Selflessness may lead a mother to pursue parenthood regardless of risk while trusting God for deliverance, but it could also be argued that in the face of expected complications, it is better stewardship to preserve the woman’s life. Sometimes it is the child who would bear the burden of a poor outcome, such as through complications of pregnancy or inherited genetic disease. In such a situation some parents may pursue other means of becoming parents, for example through adoption.

Often contraindications to child-bearing may be less straightforward and require clinical judgement on the part of medical staff, as well as prayerful consideration by those involved. Reasons to consider putting off child-bearing may include seasons of poor physical or psychological health. The same decision by two different couples may derive from entirely different motives, so we must be careful not to judge others. The decision to use contraception should be made consciously, thoughtfully and with the desire to glorify God in our choices. This is not a place for legalism.

However, none of this is to say that we should choose not to have children merely from our own selfish motives. In our ethical framework, motives are important. It is wrong to avoid having children (by using contraceptives) simply to make our lives more convenient or affluent.

Some argue that it is wrong to bring children into a world in which evil is so prevalent. But as theologian Stanley Hauerwas has argued, “Christians do not place their hope in their children, but rather their children are a sign of their hope, in spite of the considerable evidence to the contrary, that God has not abandoned this world”.[45] While Jeremiah was instructed not to marry and have children because of the coming judgement (Jer 16:1-4), once the exiles were in Babylon he wrote encouraging them to build families (29:6) as a sign that God had not forgotten his promise and would in time bring them back from captivity (29:10-14). Procreation is aligned with hope.

There are Christian couples who say they have chosen to be childless so that they may “please the Lord” (1 Cor 7:32-35), but this is faulty on at least two levels. Firstly, the passage in 1 Corinthians is discussing the situation of an unmarried Christian, for whom the intended purposes of marriage are not relevant. Secondly, it implies that an increased commitment to ministry is pleasing to God in a way that the nurture of children is not.

While I am conscious that sometimes couples who are childless through infertility are wrongly accused of selfishness, in other circumstances selfishness is indeed the reason for childlessness. There are websites dedicated to supporting those who make the choice to be ‘childfree’. They regularly deny the charge of selfishness, but the reasons given for their choice include reluctance to change lifestyle, avoiding stress on their relationship, and not wanting to take responsibility for children. Rodney Clapp sees this as a logical outcome of a society which has become increasingly individualistic, with autonomy promoted as an important ethical value: “What could hinder my autonomy more than responsibility for children, who will surely impose their own expectations and limitations on my life?”[46] I am not saying these claims are unfounded. Research into childfree couples in recent years has repeatedly shown that they tend to be happier and wealthier than their child-bearing peers.[47] But that is not the point.

As Oliver O’Donovan has written:

A deliberate intention to prefer other goods (such as career or wealth) to the good of children, would, in my opinion, constitute a lack of understanding consent and so, in traditional terms, a ground of nullity. A couple who do not see what children have to do with it are as far from understanding marriage as a couple who do not see what permanence has to do with it. But I would wish to distinguish very carefully between this couple and another who, while seeing quite clearly what children have to do with it, are persuaded for reasons that seem good to them (their age or health or genetic endowment, for example) that this good cannot be realized in their own marriage. There is a reluctant ‘intention’ not to have children which is perfectly compatible with a full understanding of marriage.[48]

But overall, justifiable reasons for avoiding children will be relatively few. It is not up to us to redesign the model of marriage we are given in the Bible and to which we commit at our wedding. Most marriages will be open to children at some point—in fact, we are to welcome children as a good gift from God.

Children as a gift

The Western world is far more affluent than any society before us. Sadly, our affluence at times seems to make us more selfish rather than less. We can now see in our society the growing acceptance of a lifestyle that excludes children entirely and allows adults to live in a completely self-centred way. In such communities, children may be seen not so much as a gift but as a threat. Life is fast-paced in the city and children make us less efficient. Kathryn Blanchard says that for Christian couples within this milieu, there is a risk that contraceptive freedom paradoxically “ends up being troubling (rather than a relief) to… Christian consciences, in that children are no longer seen as gifts from God but as consumer choices in need of explanation”.[49] This endangers the ability of Christian couples to truly welcome children. It robs us of the space to slow down and offer children the open hospitality that we ourselves have received from a gracious, loving God. In a perfect world we would have many children, and would greet them with relaxed joy and not time-pressured expectations. It is a form of Christian freedom to allow God to bless us in this way if he so chooses.

Christopher Ash has summed it up well:

If the Creator declares procreation a blessing, given to us to enable us to participate in the privilege of being his stewards in this world, we ought to value this as gift and blessing. It may be, and often is, an alarming blessing (because we are not sure if we can cope with it), an inconvenient blessing (impacting deeply on lifestyles) and a costly blessing, but it is to be esteemed as blessing not curse. This ought to be our fundamental attitude with regard to procreation.[50]

3. Understanding different contraceptives

If we accept that contraceptive use can be ethically permissible for Christians, our next question relates to whether our choice of contraceptive is morally important. Answering this question is necessary to help us judge whether our actions will be pleasing to God. However, to answer this question we first need to understand the biology of conception.

The biology

Women of child-bearing age will usually produce an egg every month, which comes from the ovary and is released into the fallopian tube (ovulation). During sexual intercourse, sperm is released from the man’s penis and travels from the vagina through the cervix into the womb and into one of the fallopian tubes. If there is an egg there, fertilization can take place.

In our biology lesson in chapter 2, we saw that this is the first step of conception. Therefore, you might be forgiven for thinking that a contra-ceptive (i.e. something which opposes conception) would just be working to keep the sperm and egg apart. Not so. Contraceptives usually work in one of three ways:

  • by stopping production of eggs
  • by preventing the egg and sperm from coming into contact with each other
  • once the embryo has been formed, by preventing it from implanting in the uterus.

However, any action occurring after fertilization means that a human life is already present when it occurs. How can a device with such an action be labelled a ‘contraceptive’?

Marketing strategies

Some history is needed to understand the marketing of contraceptives. After the introduction of the oral contraceptive pill (OCP) in 1958, Albert Rosenfeld was concerned that rather than only preventing the sperm from fertilizing the egg (the classic definition of ‘conception’), the pill might also terminate embryonic human life by inhibiting implantation (which you may remember occurs at the end of the first week). Since such interference would occur after conception, he realized that some people would say this represented an abortion. He recommended the ‘solution’ to this problem suggested by Dr AS Parkes of Cambridge: “Equate conception with the time of implantation rather than the time of fertilization—a difference of only a few days”.[51] That is, he got around the fact that these drugs might cause the termination of a pregnancy by changing the definition of when a pregnancy started—because if there were no pregnancy, you couldn’t say you were causing an abortion. (Whether this abortive mechanism does actually operate for the pill is still not clear, as we will see.)[52]

Following Rosenfeld’s logic, the subsequent printing of the American College of Obstetricians and Gynecologist’s terminology text in 1972 saw a deliberate change of the definition of ‘conception’. The accepted scientific view that conception was the result of the process of fertilization was altered to define ‘conception’ as implantation.[53] As a result, the link between fertilization and conception was broken. Pregnancy was still defined as “the state of a female after conception and until termination of the gestation”,[54] but the text now dated a pregnancy (and by implication a human life) from the time of the implantation of the embryo into the wall of the mother’s uterus. Under the new definition, any device that prevented the embryo from implanting in the uterus could be marketed as a contraceptive.

There are then two categories of marketed ‘contraceptives’: those that prevent fertilization, and those that cause an early abortion by acting after fertilization. Note that those who made this definitional change had no authority to do so—they weren’t embryologists. Despite many medical textbooks adopting the new definition, current respected embryology textbooks still mark conception (and human life) at fertilization.[55] Very few doctors currently practising are aware of this definitional change.[56]

Two kinds of contraceptive

Now, if as Christians we hold that human life begins at fertilization, we need to separate these two categories, since we would say that contraceptives that act prior to fertilization are ethically acceptable, whereas those acting after fertilization are not. We have already established that God’s law prohibits the destruction of a human embryo.[57] However, working out which contraceptive methods fit into which category is not a completely straightforward process, as we will see below.

First we must consider how a contraceptive works. This can be a problem because, surprisingly, it is still not known exactly how some standard contraceptives work. Such research is hampered by the fact that it is difficult to know exactly when fertilization occurs in any individual woman.[58] It also seems that contraceptive manufacturers are quite happy to have some doubt surrounding the precise mechanisms of contraceptives, as it makes it more difficult for pro-lifers to object to them on factual grounds. I will do my best to clarify how particular contraceptives work as I discuss each one.

In the discussion of individual contraceptives below, effectiveness ratings are included as failure rates. No contraceptive works perfectly. Sometimes they fail. Failure rate refers to how well it works in terms of preventing pregnancy, and the way it is listed refers to the percentage of couples who will become pregnant in the first year of use. It does not refer to how ethical it is in terms of function. I have included this information not only because reliability will obviously be a factor worth considering when choosing a contraceptive, but also because some people have the idea that by making ethical choices in this area they are opening themselves up to the risk of unreliable birth control. The figures don’t support this.

In this chapter, failure rates are recorded as a range between ‘consistent and correct use’ (which looks at how well the method of contraception works if used perfectly according to the instructions) and ‘as commonly used’ (which takes into account someone forgetting a dose or experiencing drug interactions, and other aspects of real life).[59] ‘Failure rate’ of using no method at all is 85%, meaning that 85% of couples will become pregnant in the first year if no contraception is used.

Check with your doctor regarding how a particular contraceptive method should be used, any risks involved, and how long you need to be using it before it starts working properly.

Choosing a contraceptive

A final note of caution: this section is not designed to take the place of the medical consultation that is necessary to ensure contraception will be safe and appropriate for your own situation. This is because choosing which contraceptive you would like to use involves consideration of more than ethics alone. Once you have determined which contraceptives are ethically permissible, you will also need to take into account factors such as the state of your health, side effects of different methods, availability and cost. Before deciding which one suits you, I recommend you discuss the issue with your doctor. Most doctors will be happy to take your ethical position into account while exploring the alternatives.

Some people may reject a certain contraceptive (such as the pill) because of the social context in which it was developed. I would suggest that while this may make us look at an individual method more carefully, it should not lead us to reject it out of hand. Ethics is a rational process of inquiry that, in medical decision-making, should be based on the facts.

This chapter discusses the use of contraceptives for the purpose of avoiding pregnancy.[60] The discussion below assumes that the reader is in a Western industrialized society. There may be different ethical factors to consider in a developing country where maternal mortality and associated newborn mortality need to be taken into account.

For convenience I will group the various methods under the following headings:

  1. Hormone contraceptives
  2. Barrier contraceptives
  3. Intrauterine Devices (IUDs)
  4. Fertility awareness
  5. Male contraceptives
  6. Other methods
  7. Permanent contraception
  8. Emergency contraception

a. Hormone contraceptives[61]

There are two main types of hormone contraceptive formulations available:

  • combined, which contain both an oestrogen and a progestin (a synthetic form of the natural hormone progesterone)
  • progestogen-only, which contain only progesterone or progestin.

It is easier to understand how these contraceptives work if you are aware of the normal 28-day human female reproductive cycle. The changes that occur in the ovary and uterus during each cycle serve to develop and release the egg for possible fertilization by the sperm, and prepare the endometrium (uterine lining) for implantation of the fertilized egg.[62]

During the first half of her menstrual cycle, an egg develops in a follicle of a woman’s ovaries in response to a hormone stimulus (follicle stimulating hormone, or FSH). The follicle increases oestrogen production, which acts on the uterus to stimulate growth of the endometrium. It reaches a peak about one day before ovulation (release of a mature egg into the fallopian tubes). The surge of oestrogen stimulates her pituitary gland to secrete another hormone (luteinizing hormone, or LH), which in turn triggers ovulation.

The follicle that released the egg then transforms into another type of cell (a corpus luteum) under the influence of LH. The corpus luteum produces high levels of oestrogen and progesterone, which stimulate continued growth of the endometrium to prepare it for implantation of an embryo if there is one. During an ovulatory cycle, estradiol levels increase by 10-16 times, and progesterone increases by 20 times, compared to pre-ovulatory levels. If fertilization does not occur, the corpus luteum reduces in size and stops secreting hormones, leading to the shedding of the endometrium as a menstrual period. If fertilization does occur, the corpus luteum continues to secrete its hormones for 8-10 weeks until the placenta takes over production of the hormones to support the pregnancy.

INSERT DIAGRAM 6: menstrual cycle

There are several different types of hormone contraceptives, including the oral contraceptive pill, progestin-only pills, implants and injectables, and hormone-containing patches and rings. As they vary in method of action and effectiveness, they will be considered individually.[63]

(i) The oral contraceptive pill (OCP)

Also known as the combined oral contraceptive (COC), the birth-control pill and ‘The Pill’, this is an oral contraceptive that contains low doses of two hormones—a progestin and an oestrogen. There are many brands available that vary in strength and other factors, but they essentially all work the same way. The OCP is taken daily for 3 weeks followed by a week when either a sugar pill or no pill is taken before resuming the OCP.

OCPs inhibit follicular development and prevent ovulation as their primary mechanism of action. This is achieved through suppression by progestin of the release of FSH and LH. Oestrogen was originally included in the OCP for better cycle control (stabilizing the endometrium to reduce breakthrough bleeding), but was also found to inhibit follicular development and help prevent ovulation.[64] This means there is no egg available to be fertilized.

A secondary mechanism action of all progestogen-containing contraceptives is inhibition of sperm penetration through the cervix by decreasing the amount and increasing the viscosity (stickiness) of the mucous in the cervix. This reduces the chance that sperm will be present to do the fertilizing.

The OCP also has a third effect. It makes the lining of the womb thinner and hostile to the embryo. These changes to the endometrium may prevent implantation of an embryo in the uterus, should one be present.[65] If the first two mechanisms failed and this post-fertilization mechanism did operate, then use of the OCP may sometimes cause early abortions, in which case its use is unethical. However, if this third mechanism does not operate alone, then there are no ethical objections to use of the OCP. Although in scientific terms this controversy is currently unresolved, my own view is that the weight of evidence supports OCPs as being ethically acceptable—but see appendix I for a fuller discussion of these issues.

It is well known that the mechanism of the OCP is less reliable in suppressing ovulation in certain circumstances: in the first month of use, when a dose is missed, when the tablets are not absorbed from the gut (e.g. due to vomiting and diarrhoea), and when other drugs interfere with the pill (e.g. some antibiotics). At these times I would advise using an alternative method of contraceptive (such as a condom). This is because the OCP will be less effective, not because I think you are risking an early abortion. You need to discuss these things with your doctor, but they explain why the OCP failure rate is wide at 0.3%-8.0%.

For doctors

For added security, to reduce the likelihood of ovulation you could consider shortening the pill-free interval to 4 days on a regular basis, or recommend 2-, 3-, 4-monthly or continuous extended use of the pill. Monophasic pills (where there is the same amount of oestrogen and progestin in each pill) are recommended for extended use.[66] It is important to take the time to educate patients regarding the significance of the pill-free period—that is, that missing a pill at the start of a packet or extending the pill-free period for more than 7 days significantly increases the chance of ovulation occurring.[67]

As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risk for those who wish to avoid this, it is recommended that a couple use a barrier method of contraception until after the woman’s second period when ceasing the OCP.[68]

(ii) Extended cycle and continuous use birth control pills

These are usually known by their brand names: Seasonique, LoSeasonique, Lybrel (all contain levonorgestrel and ethinyl estradiol).

In 2003, the FDA approved use of extended regimen birth control, which was intended to let women have fewer periods (withdrawal bleeds) or none at all. It has a similar makeup to older OCPs but is packaged differently. The extended use involves taking one pill for 84 days continuously, followed by a different pill for 7 days, which means a woman will have only 4 periods a year. The continuous use is just one pill taken without a break, with no period until she stops. At this stage it is thought that extended use pills are as safe as the conventional pill in the short term (obviously no long-term studies are available yet), and of similar effectiveness, although details of the failure rate are not known at the time of writing. Missing a period is safe—but many women are reassured by the appearance of a period, to know that pregnancy is unlikely. Ethics of use will be similar to the OCP (see above).

Seasonique and LoSeasonique are taken 84/7. Lybrel is taken continuously. They currently have limited distribution.

For doctors

You will recognize this application as similar to tricycling conventional OCPs, which has long been done by women wanting to avoid a monthly withdrawal bleed. This has often been used to treat endometriosis, dysmenorrhea and other menstruation-associated symptoms. Personal preference to avoid menstruation has become a common reason for use of the new formulations,[69] especially amongst teenagers.[70] Please see prescribing information for details of use and side-effect profile. At present the exact efficacy is unknown and there is no available data at this time concerning the long-term effects of menstrual suppression on a woman’s overall health. There exists concern in the medical field that increasing the amount of hormones typically taken by a woman may have an adverse effect on her long-term health, but there is no data to confirm or disprove this.

Whatever you decide with your spouse on this matter, do not use the pill if the conscience of either of you forbids it. Everything that does not come from faith is sin (Rom 14:23b). This implies that an action performed against the voice of an informed conscience can never be right.

(iii) Progestin-only injections

The most commonly used progestin-only injectables are DMPA (medroxyprogesterone acetate; e.g. Depo-Provera, Depo, Megestron, Petogen) and NET-EN (norethisterone enanthate; e.g. Noristerat, Syngestal). They are packaged in the form of an injection that is given regularly (3-monthly for DMPA and 2-monthly for NET-EN for greatest effectiveness). They are usually given into the muscle, and from there the hormone is slowly released into the bloodstream. (A newer formulation of DMPA called depo-subQ provera 104, or DMPA-SC, is injected under the skin and has similar effects.)

These contraceptives mainly work by suppressing ovulation (so there is no egg), and they also thicken cervical mucus (to slow down the sperm) and make the endometrial lining thinner. The dose of progestin used reliably suppresses ovulation, so there is never an egg available to be fertilized. As there is no embryo created, the other mechanisms of action do not contribute to the contraceptive effect. Just because they are capable of blocking implantation does not mean these drugs ever have to use this back-up mechanism. They are therefore ethically acceptable, so long as they are injected on time. They can be used in breastfeeding from 6 weeks after childbirth. They have increased effectiveness compared to other medications because you don’t have to remember to take a pill every day. Failure rate is 0.3%-3.0%.

For doctors

In these drugs, progestin suppresses ovulation through the hypothalamic-pituitary-ovarian axis, controlling LH and FSH release so the ovum does not mature. To ensure suppression of ovulation it is important that the injection period is never exceeded. It is possible for minimal follicular activity to occur towards the end of the injection period in some women. For extra confidence that ovulation is suppressed, you could offer injections more frequently—for example, every 10 weeks for DMPA instead of the usual 12.[71]

As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects can occur while ovulation is being re-established. To avoid any risk for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s first period after stopping Depo-Provera.[72]

(iv) Combined injectable contraceptive

Monthly injectables, also called CICs, contain the two hormones—a progestin and an oestrogen—similar to the oral contraceptive pill. This makes them different from DMPA and NET-EN, which contain progestin only. Two common combinations are medroxyprogesterone acetate (MPA)/estradiol cypionate (Ciclofem, Ciclofemina, Cyclofem, Cyclo-Provera, Feminena, Lunella, Lunelle, Novafem) and norethisterone enanthate (NET-EN)/estradiol valerate (Mesigyna, Norigynon). They work primarily by preventing the release of eggs from the ovaries (ovulation). There are few long-term studies for monthly injectables, but researchers assume they are similar to the OCP in effect. This means that the ethics for using this formulation will be similar to that of the OCP (see above). Injections need to be given regularly every 28-30 days. Failure rate is 0.05%-3%.

For doctors

As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risk for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s first period after stopping monthly injectables.

(v) Progestin-only pill (POP)

This is a pill that contains only a low dose of progestin (levonorgestrel or norethisterone). It is also called the mini-pill (because it is a low dose), or by its brand name: Femulen, Micronor, Microval, Noriday, Neogest, Norgeston. It is often prescribed for breastfeeding women (starting 6 weeks after the birth) as it does not contain oestrogen, which can reduce milk production. It may also be recommended for older women who smoke, as taking oestrogen greatly increases the risk of developing a blood clot in this group.

POPs appear to work by thickening cervical mucus so that the sperm cannot get through and inhibiting ovulation so there is no egg (both pre-fertilization effects), and by making the endometrium hostile to an embryo (a post-fertilization effect). When used alone (without breastfeeding), the low dose of progestin makes it unreliable in terms of suppressing ovulation, with estimated ovulation rates with ‘typical’ use averaging at about 50%. It is also not guaranteed to block all the sperm from getting through. This means that it will be possible for a sperm and egg to unite and create an embryo that may not be able to implant in the endometrium, because the POP may have made the lining of the uterus too thin to allow the embryo to implant and develop normally. Therefore, as it will sometimes work post-fertilization if used alone, it will be an unethical choice for Christians under these circumstances. When used alone, failure rate ranges from 0.3%-8.0%.

The POP is more successful in suppressing ovulation when combined with breastfeeding, provided it is taken conscientiously (at the same time every day). The timing is important because the contraceptive action decreases rapidly after 24 hours. Under these conditions, failure rate ranges from 0.1%-3.0%. Suppression of ovulation would make this contraceptive ethically acceptable. As weaning begins, the risk of breakthrough ovulation and therefore use of the post-fertilization anti-implantation mechanism increases. As soon as the baby starts getting nutrition from somewhere other than breastfeeding, the woman should use different or additional (barrier) contraception. (See lactation amenorrhoea method, below, or progestin-only injectables, above, for alternatives for breastfeeding women.)

For doctors

Research on POPs has been limited. It is thought that when they do interfere with ovulation, POPs work by suppressing the mid-cycle peak of LH and FSH.[73] It is critical that POPs be taken at the same time every day to be maximally effective. A formulation of the POP using desogestrel 75 mcg (Cerazette) is more reliable in suppressing ovulation than older forms (with evidence of 97% anovulation), and the manufacturers of Cerazette now advertise the flexibility of a 12-hour ‘missed pill’ window that is similar to OCPs.[74] Cerazette is not available in all countries.

If a woman menstruates regularly while taking a POP, it is unlikely that her ovulation has been suppressed. While no bleeding may indicate ovarian suppression, it may also indicate pregnancy.

As there is no research into the residual effects of hormonal contraceptives when they are stopped, it is impossible to tell whether post-fertilization effects are possible while ovulation is being re-established. To avoid any risks for those who wish to avoid them, it is recommended that a couple use a barrier method of contraception until after the woman’s second period after stopping the POP.[75]

(vi) Implants

Implants (Implanon, Jadelle, Zarin, Femplant) are small plastic rods or capsules that are usually inserted under the skin of the inner arm by a healthcare worker. They continuously release a progestin at a very slow rate. They work by thickening cervical mucus (to prevent the sperm from getting through) and suppressing ovulation (so there is no egg). They also cause some changes to the endometrium (but less than other progestogen-containing contraceptives). Implants are similar to the POP in the way they work, but they have a much lower pregnancy rate because compliance is not a problem (you don’t have to remember to take a pill every day). Etonogestrel (Implanon) implants are so effective in suppressing ovulation that it is fair to say they operate prior to fertilization. Just because they are capable of affecting implantation in the endometrium does not mean they ever have to use this back-up mechanism. This makes them an ethical choice. There are other types of implants that release the hormone levonorgestrel (e.g. Jadelle, Norplant II, Sino-implant II sold as Zarin, Femplant), which are less reliable in their suppression of ovulation and so would not constitute an ethical choice. Implants need to be replaced after a period of 3 (etonogestrel) or 4 (levonorgestrel) years. Implants are considered the most reliable contraceptive method; failure rate is only 0.05%-0.05%. The pregnancy rate associated with the use of Implanon is very low (fewer than one in 1000 over 3 years).

For doctors

Studies show that ovulation may occur towards the end of the 3-year period, so if a woman wanted extra reassurance that ovulation would be avoided you could consider replacing Implanon every 2½ years instead of the usual 3 years.[76]

There is no research into the residual effects of hormonal contraceptives when they are stopped. In the case of Implanon, we cannot be sure whether it continues to act partially after ovulation has returned. We do know that Implanon has less impact on the thinning of the endometrium than other progesterone-only contraceptives, and so is unlikely to interfere with implantation by this effect. However, if your patient wants to be sure to avoid any post-fertilization action, she should use a barrier method of contraception until after her second period after the Implanon is removed.[77]

(vii) Combined patch

The combined patch (Evra, Ortho Evra) is a small adhesive plastic patch worn on the skin that continually releases two hormones, a progestin (norelgestromin) and an oestrogen (ethinylestradiol), through the skin into the bloodstream. The patch is replaced once a week for 3 weeks and then no patch is worn for a 4th week at which time a withdrawal bleed takes place, and then you start again with a new patch. Method of action and ethical challenges are similar to the OCP (see above). Failure rate is 0.3%-8.0%.

For doctors

At the time of writing, Evra has been associated with potentially life-threatening complications that should be considered when prescribing contraceptives. The incidence of complications is greater with Evra than with a typical OCP, due to the proportionally greater percentage of oestrogen the woman is exposed to by the topical route.[78] Evra is not available in all countries.

For increased effectiveness of ovulatory suppression you could advise using patches continuously for 2 or 3 cycles (6-9 weeks), followed by a shorter rest interval (4-6 days).[79]

(viii) Combined vaginal ring

The combined vaginal ring (NuvaRing) is a small flexible vaginal ring about 5 cm in diameter that you insert vaginally once a month. It contains hormones similar to those in the OCP (oestrogen/ethinylestradiol and progesterone/etonogestrel). The hormones are absorbed into the bloodstream through the lining of the vagina. It is inserted at the beginning of a menstrual cycle and removed after 21 days, allowing the withdrawal bleed, and then a new ring is inserted after a 7-day break. Method of action is similar to the OCP. For the ethical challenges, please review the OCP section above. Experience is limited but failure rate appears to be 0.3%-8.0%.

For doctors

As with the combined patch, is possible to increase confidence that ovulation has been suppressed by using 3 or 4 rings in a row without a break.[80]

b. Barrier contraceptives

Physical barriers placed between the sperm and egg always work before fertilization because they prevent the embryo from being formed. This makes them all ethically permissible for Christians. To be reliable, devices need to be in good condition and used according to directions. Several alternatives are available.

(i) Male condom

The male condom looks like a balloon before you blow it up. It is a mechanical barrier made of latex, polyurethane or natural membrane. It fits over the husband’s erect penis and prevents fertilization by stopping semen and therefore sperm before, during and after intercourse. Failure rate is 2%-15%. Problems with condom failure can be caused by manufacturing defects but are more often due to incorrect use. For instance, latex condoms should not be used with oil-based lubricants such as baby oil or petroleum jelly (Vaseline) because they can damage the latex. While using spermicide with a condom would seem likely to increase contraceptive protection, it has never actually been proven to do so. Some condoms are manufactured with a spermicide coating anyway.

(ii) Female condom

These are generally known by their brand names: for example, Care, Reality, Femidom. A female condom consists of a pouch made of thin polyurethane or latex with flexible rings on both sides. It fits loosely inside the woman’s vagina and prevents fertilization by stopping sperm from entering the cervix. Failure rate is 5%-21%.

(iii) Diaphragms, cervical caps and the sponge

These are barriers made of soft rubber or latex, or polyurethane foam (the sponge), which are inserted into the vagina before sex to cover the cervix. The diaphragm is a shallow, dome-shaped cup with flexible rim, which also covers part of the vagina; the cervical cap and the sponge are designed to fit over the cervix only. Use with spermicide (see below) is recommended to improve effectiveness. They come in different sizes and need to be fitted by a trained provider, but are then inserted by the wife when needed. They work by stopping the sperm from entering the cervix, and the spermicide kills or disables the sperm. Failure rate is 6%-16% for diaphragms used with spermicide. Failure rate for cervical caps is different depending on whether a woman has previously given birth (26%-29%) or not (9%-16%). This difference is thought to be related to whether the couple is just delaying pregnancy or trying to avoid it altogether, which influences how careful they try to be. The sponge has a failure rate of 9%-32%. Note that it has been reported that use of vaginal barriers is associated with Toxic Shock Syndrome, a rare but potentially fatal illness.[81]

(iv) Spermicides

Spermicides are creams, jellies, gels, pressurized foam or pessaries (tablets) that are inserted deep in the vagina, near the cervix, before sex. They are designed to break the membrane of sperm cells, which either slows their movement or kills the sperm. This stops the sperm from meeting the egg and so avoids fertilization. The most common spermicide is nonoxynol-9 (Gynol II), which causes damage to the vaginal wall when used frequently. Spermicides need to be applied each time you have sex—for example, if you have sex more than once in an evening, you need to reapply the spermicide each time. Alone, spermicides are considered less effective than if used with a barrier method: failure rate is 18%-29%. This is a bit misleading, because you are always meant to use them with a barrier method. Foams and sponges are the most reliable.

New non-toxic spermicides are currently being developed, as well as spermicidal microbicide gels (BufferGel, PRO2000 gel), which aim to provide dual protection against pregnancy and sexually transmitted infections (including HIV). These gels act by making the vagina more acidic so that both sperm and infections are unable to survive. It is applied in the vagina before sex, and in trials has been used with a diaphragm. If this product became available it would be ethically permissible, as it would act before fertilization.

c. Intrauterine devices

Intrauterine devices (IUDs, also known as coils—the shape of early IUDs) are small, usually T-shaped devices that are inserted into the uterus through the vagina and cervix by a healthcare provider. They can stay in place for a number of years, depending on the type. Almost all types of IUD have one or two threads tied to them that hang through the cervix into the vagina. Even though they have been around for a long time, the contraceptive effect is not completely understood. All IUDs appear to induce an inflammatory reaction that changes the chemical climate of the entire genital tract. This is a result of the body recognizing that the IUD is foreign, and trying to destroy it. In humans, the cells that are produced to do this flow out of the uterus into the fallopian tubes. The main outcome of this is thought to be a reduction in the rate of fertilization.[82] This means the common belief that IUDs work mainly by stopping an embryo from implanting in the wall of the uterus is incorrect.[83] But while we cannot be sure exactly how they work, we do know that it is possible for the sperm to reach the egg when there is an IUD in place, because occasionally a case of ectopic pregnancy (pregnancy where the embryo implants in the fallopian tube) occurs with this method. This means there can be a post-fertilization effect that makes this method ethically unacceptable.

There are two types of IUD with frames: inert (or copper-bearing) IUDs, and hormonal IUDs, which release progestogen. There are also two frameless (implantable) types of IUD: copper-bearing and hormone-releasing.

(i) Inert and copper-bearing IUD

Most non-hormonal IUDs contain copper, which increases the toxicity for sperm and egg. (Some may also contain silver, which has a similar effect to copper.) This, along with the chemical changes in the reproductive tract, damages the egg and sperm before they meet, reducing the rate of embryo production. But if an embryo is created, the altered environment means that its chance of survival becomes worse as it approaches the uterus.[84] Although they mainly act before fertilization, there is definite evidence that inert and copper IUDs can work after fertilization.[85] This means that they are not ethically acceptable as a form of contraception for those who value human life from the time it is created. Failure rate (copper-bearing IUD) is 0.6%-0.8%. The copper IUD is sometimes used after unprotected intercourse for emergency contraception (see below).

(ii) Hormonal IUD (Mirena)

These IUDs are impregnated with a hormone, levonorgestrel, which is similar to the hormone progesterone. In some places they are distinguished from copper IUDs by being called ‘intrauterine systems’ (IUS). They have some systemic effects such as thickening cervical mucus (inhibiting sperm movement through the cervix) and reducing the thickness of the endometrial lining. Despite the addition of hormones, there is evidence that not all women who use a progestin IUD have unfavourable cervical mucus, and for most women the dosage is insufficient to suppress ovulation.[86] The main effect is local. The IUS causes damage to both sperm and eggs, interfering with the way they function and reducing survival, and so decreasing the rate of fertilization. It also lowers the chance of survival for any embryo that might be formed in the fallopian tube before it gets to the uterus. This last mechanism operates after fertilization,[87] making the IUS an unethical choice for contraception. Failure rate is 0.2%-0.2%.

d. Fertility awareness

Fertility awareness methods involve teaching a woman to recognize when she is fertile, or able to become pregnant. Couples use this information to time unprotected intercourse. There are no ethical objections to this method of contraception.

(i) Natural family planning (NFP)

NFP (also called ‘periodic abstinence’) is an umbrella term for many different types of fertility awareness methods. By identifying on which days the woman can become pregnant, a couple can avoid pregnancy by either abstaining from vaginal intercourse or using another method of ethical contraception (usually a condom or other barrier method) on those days. The aim of each method is to reduce the number of days of abstinence in each menstrual cycle as far as possible without risking conception. There are several methods available, and fertility indicators can be used alone or in combination to identify the fertile period. Use of more than one indicator is more effective.

Methods of telling when a woman is fertile include the following:

  • Calendar-based methods involve keeping track of days of the menstrual cycle (e.g. the calendar method, standard days method and calendar rhythm method).
  • Cervical secretions can be observed for changes around the time of ovulation (e.g. ovulation [Billings] method).
  • Basal body temperature (BBT) or body temperature on waking can be measured through the month. It goes up after ovulation (e.g. two day method, BBT method, temperature method).
  • Sympto-thermal method or multiple index method uses all the available indicators of fertility to indicate infertile and fertile phases of the month.

Using these methods, a woman can learn to assess her fertility without the use of a computerized device.

Computerized fertility monitors are also available, which may track basal body temperatures, hormonal levels in urine, changes in electrical resistance of a woman’s saliva, or a mixture of these symptoms. For example, Persona detects luteinizing hormone and oestrogen (the hormones that control your cycle), and the WinBOM Charting System can be used with the Billings method. Lady-Comp is a variation of the rhythm method, as is CycleBeads. These are meant to identify the days on which you are at significant risk of becoming pregnant, and on which you should avoid intercourse if prevention of pregnancy is intended.

This technique will not suit every couple. You must be highly motivated to stay aware of the woman’s body cycle and keep track of the days, and both husband and wife must be committed to the program. The fertile window is usually 8 days, and vaginal intercourse should be avoided during that time. We are instructed in 1 Corinthians 7:5 that abstinence within marriage is to be undertaken only by mutual consent. However, though it sometimes causes stress, many couples have reported that this style of contraception has increased intimacy and strengthened their marriage as they share responsibility for contraception. Some have reported that the periodic abstinence has kept their sex life fresh and entertaining. And this contraceptive is free and always available!

The Roman Catholic Church approves of NFP while opposing use of other ‘artificial’ contraceptives (such as those listed above).[88] While NFP does differ in terms of equipment required, the intention is the same (to avoid pregnancy), and deliberate action is still taken to prevent fertilization with the outcome of (hopefully) avoiding pregnancy. Accordingly, I do not consider NFP to be superior in ethical terms to other ethically permissible methods described in this chapter.[89]

There’s an old joke: “What do you call a couple who uses the rhythm method? Parents!” But this is no longer necessarily the case. Failure rate of NFP is 3%-25%. Pregnancy rates will vary for different types of fertility methods, with calendar/rhythm methods used alone being the least reliable. One German study found NFP to have a failure rate as low as 0.3%, which is similar to the OCP.[90] It depends on the users and the regularity of the woman’s cycle. NFP needs to be taught by a trained instructor and used carefully to be this reliable.[91]

(ii) Lactation amenorrhoea method

The lactational amenorrhoea method (LAM) is the strategic use of breastfeeding as a contraceptive method. Breastfeeding normally results in amenorrhoea (no menstruation). This reflects a delay in the return of fertility after giving birth, which is mainly due to the baby’s suckling (of the mother’s nipples) blocking ovulation through hormone release. The length of this delay cannot be reliably predicted or detected. With LAM, a new mother uses frequent breastfeeding without supplementary feeds for the first 6 months as a way of preventing pregnancy. When used properly, so long as bleeding has not returned, LAM is more reliable as a contraceptive than the mini-pill (failure rate is 0.9%-2.0% compared to 0.3%-8.0%).[92] The technique can be learnt through centres that teach natural family planning. It needs to be followed carefully, but does not involve periods of abstinence. Extended LAM (more than 6 months) is less effective.

e. Male contraceptives

When some women describe what they want as a male contraceptive, it looks something like a pregnant man in labour. I don’t think that’s coming anytime soon! However, there are other developments on the horizon.

(i) Male hormonal contraceptives

This type of contraceptive is still at the research trial stage. It involves giving hormones to men in order to reduce sperm production, and is given as an injection, an implant, patches or pills.[93] If it did reliably remove sperm from the ejaculate then it would be an ethical choice of contraceptive, as that would make fertilization impossible. (You need both the egg and the sperm for fertilization to take place.)

(ii) Contraceptive vaccine

A class of contraceptives based on immunocontraception is being investigated. Theoretically, the vaccine acts against a chemical involved in fertilization in the body, stopping it from functioning normally. If this product were available it would be ethically permissible, as it would not cause the loss of an embryo.

(iii) Other methods

Other strategies aimed at reducing sperm production (spermatogenesis) and/or function are in the pipeline. These include techniques such as heating the testes and blocking the vas deferens (the tube that carries the sperm from the testis) with plugs, traditional Chinese medicine plant Tripterygium wilfordii and other medications such as Adjudin, enzyme inhibitors and even blood pressure medicine.[94] If the contraceptive is aimed entirely at blocking sperm production or function, it will be ethically permissible as it will always act before the embryo is formed.

f. Other methods

(i) Coitus interruptus (withdrawal method)

The withdrawal method is really self-explanatory. It involves the husband withdrawing his penis from his wife’s vagina before ejaculating outside the vagina. He keeps his semen away from her external genitalia. It works by keeping the sperm outside the woman’s body, so fertilization cannot occur. As mentioned above, it has a long history and is the only contraceptive method explicitly mentioned in the Bible. It is more effective than using no contraceptive technique, but challenges in its timing can cause anxiety between couples attempting to avoid conception. It requires a high degree of self-control if it is to be done properly. It therefore has the potential to reduce the pleasure of the marital act, and we know from Scripture that pleasure is an important aspect of marital sex.

However, it is free, is always available, does not cause weight gain, and is known to be acceptable to many married couples. There are no specific ethical objections to its use. The decision to use this method should be based on mutual preference. Failure rate is 4.0%-27.0%. It is possible to fail even if the withdrawal is properly timed, because the pre-ejaculate (fluid that comes out of the penis before the semen) can sometimes contain sperm.[95] Effectiveness can be increased with the use of spermicide.

(ii) Abstinence

Abstaining from vaginal intercourse is the most reliable way to avoid pregnancy in a fertile woman. But is it a contraceptive method that Christians should use?

Some writers see a justification for abstinence in Old Testament regulations. Sexual intercourse was to be avoided during menstruation (Lev 15:24, 18:19, 20:18), after childbirth (Lev 12:1-8), and by men before special missions (Exod 19:15; 1 Sam 21:4-5)—though in the Leviticus passages it was not forbidden completely. These practices would not have been intended as a form of birth control, since by avoiding intercourse at the time of menstruation the couple would be more likely to come together immediately after this period of abstinence, at a time when the woman is more likely to be fertile. This would act in a way directly opposite to contraception. The restrictions on men are not specified, but do not suggest an extended time (less than 3 days in the Exodus passage). Furthermore, these passages are not placed in the context of a discussion of sexual relationships within marriage.

The Bible teaches that sexual intimacy is to be the norm within marriage:

The husband should give to his wife her conjugal rights, and likewise the wife to her husband… Do not deprive one another, except perhaps by agreement for a limited time, that you may devote yourselves to prayer; but then come together again, so that Satan may not tempt you because of your lack of self-control. (1 Cor 7:3-5)

Within marriage, abstinence should be practised only for specified time periods, by mutual agreement for the purpose of prayer. Then the couple should resume sexual relations due to the moral danger that abstinence represents. The apostle certainly does not encourage total abstinence, since that would encourage the temptation to immorality—which, according to Paul, is the opposite of what sexual relations in marriage are intended to do.

According to the Bible, married couples are to engage in regular sexual intercourse. Abstinence is not a long-term birth control method that should be used by married Christian couples. 

(iii) Abortion (surgical, RU-486)

Of the estimated 208 million pregnancies that occurred worldwide in 2008, 33 million (16%) resulted in unintended births and 41 million ended in induced abortions (20%).[96] The Guttmacher Institute sees unintended pregnancy as one of the main drivers of abortion. Modern society’s belief that procreation does not have to result from sexual relations has meant that some couples see abortion as a way of ‘avoiding’ pregnancy.

Several methods of abortion are available depending on the stage of pregnancy. Induced abortions include surgical procedures and/or the use of medications such as RU-486. RU-486 is not a contraceptive. It was specifically designed to cause abortions. All forms of induced abortion are ethically wrong to use as contraceptives, as they directly lead to the death of an unborn child. While it is possible for a late-term abortion to accidentally result in a live birth, this is never intended; and in early pregnancy, abortion is uniformly fatal for the unborn child. We do not have definitive data regarding how many woman use abortion as a means of contraception. It is possible that women who have more than one abortion may be using it this way. For example, the only state in Australia that collects complete data on abortions is South Australia. In that state for the year 2008, of the 5,101 women who had terminations of pregnancy, 1,860 (36.5%) had had a previous termination.[97]

(iv) Ormeloxifene

Also known as centchroman, or trade names Saheli, Novex-DS, Centron and Sevista, ormeloxifene is a selective oestrogen receptor modulator (SERM), a class of medication that acts on the oestrogen receptor. It is a non-hormonal, non-steroidal oral contraceptive that is taken once per week (after the first 16 weeks, when it is advised to be taken twice weekly). It causes disruption in the menstrual cycle between ovulation and the development of the uterine lining, although its exact mode of action is not really known. It may delay ovulation, and seems to cause the lining of the uterus to build more slowly than usual. At the same time, if an embryo is formed ormeloxifene makes it travel more quickly through the fallopian tubes than normal. It is thought that this combination of factors creates an environment where, if an embryo forms, implantation is impossible.[98] This means that ormeloxifene will not be an ethical choice for those who value human life from the time of fertilization. Failure rate (estimated from clinical trials) is probably around 2%-9%.

g. Permanent contraception

Sterilization as a means of contraception involves a surgical procedure that intends to prevent pregnancy on a permanent basis by physically blocking the egg and sperm from coming into contact with each other. It is clearly a true contraceptive that prevents fertilization, and in that sense is ethically acceptable.

However, we need to think about whether it is consistent with biblical teaching to permanently terminate a person’s fertility. Sterilization is seen as a convenient form of contraception for those couples who do not expect to desire more children. But therein lies the problem. We might not expect it, but we can’t predict what is in store for any of us. Even if you don’t want more children now, consideration should be given to future changes of situation, such as the death of a child or spouse, which may lead you to want more children after all. Young widows are instructed to remarry and have children in 1 Timothy 5:14. The decision to be sterilized potentially robs your future spouse of the opportunity to have children with you.

A study of over 11,000 women in the United States found that 5.9%-20.3% regretted sterilization. The largest score was for women 30 years of age or younger at the time of sterilization.[99]

While some methods are potentially reversible, it is technically difficult to reverse sterilization and can never be guaranteed. Even when it is reversed, the fertility rate isn’t 100%. It is not the intention at the time the surgery is performed to make it reversible. (If you wanted reversible contraception you would use one of the methods above that is reliably reversible.)

Traditional arguments against sterilization tend to focus on the morality of purposely setting aside a bodily function or removing part of the body. Is this a proper way to treat the body as a “temple of the Holy Spirit” (1 Cor 6:19-20)? As previously mentioned, passages such as Deuteronomy 23:1, where those emasculated by cutting are forbidden from entering the assembly of the Lord, are thought to refer to a prohibition of Canaanite cultic practices. Jesus’ discussion about eunuchs in Matthew 19:10-12 is addressing the idea of not marrying, rather than celibacy in marriage, and points out that only those “to whom it is given” can receive this teaching. Neither passage is a discussion of contraception.

If we consider sterilization in the context of stewardship of the body, we might question whether surgical removal of part of the body is permissible for reasons of convenience, especially when safe and reliable alternatives exist. However, we can also use this as an argument for sterilization, since it may be good stewardship for some individuals (such as a woman whose body is not fit to carry another pregnancy to term) to ensure that future pregnancy is impossible.

A further argument against sterilization suggests that it makes one unable to fulfil the command of Genesis 1:28. But we have already discussed that this verse cannot represent a universal requirement to reproduce.

If we accept that there is a place for contraception at all, on the grounds that sexual intercourse has a unitive function that can operate independently of the procreative function, then it’s hard to see an objection to this particular form of contraception. It is reasonable to think that a couple may get to the point of believing they have as many children as they can responsibly provide for, and their desire to avoid the condemnation of 1 Timothy 5:8 (that “if anyone does not provide for his relatives, and especially for members of his household, he has denied the faith and is worse than an unbeliever”) leads them to consider sterilization. Furthermore, we know that fertility for women is never lifelong, as God has built into the female body a sterilization of sorts through the normal process of menopause.

If we understand the underlying theology of responsibility in relationships, we can distinguish good and evil motives for sterilization. There won’t be a general ‘yes’ or ‘no’ to sterilization; it will depend on each individual case. But the irreversibility of the procedure demands careful consideration, especially if you are in a younger age group.

If the motivation for sterilization is convenience and the desire to separate contraception from sex, or to avoid the necessity of daily tablet-taking, you could consider the use of a longer-term reversible contraceptive (such as Implanon) as an alternative.

If a couple decides to proceed with sterilization then unless there are other reasons for the woman to undergo surgery (for example, she needs to have a hysterectomy for fibroids anyway), it is preferable for the man to undergo a vasectomy. It is cheaper and safer than female sterilization. Because of its permanent nature, it is important that the person undergoing sterilization is fully aware of the consequences and consents freely to the operation.

(i) Female sterilization

There are two main ways to remove the reproductive capacity of women, both usually carried out under general anaesthetic. Failure rate overall is 0.5%-0.5%. (Failure of tubal occlusion can occur years after surgery.)

  • Tubal occlusion: Tubal occlusion (‘tying the tubes’) involves blocking or removing part of the fallopian tubes so that the egg cannot reach the reproductive tract. This can be achieved by placing a band or clip over each fallopian tube, or electrically burning the tubes. Alternatively, the mid-part of each tube can be surgically removed. A newer technique called Essure involves placing tiny coils into each fallopian tube that promote the growth of scar tissue, which in turn blocks the tubes. This can be performed without general anaesthesia.
  • Hysterectomy: Hysterectomy is the surgical removal of the uterus. While this is extremely effective as a form of sterilization, the operation is too risky to be performed for this purpose only.

(ii) Male sterilization

Vasectomy is the most common form of male sterilization. It is usually done under local anaesthetic, and involves cutting the vas deferens (the tubes that carry the sperm from the testes where they are made), so that no sperm enters the normal ejaculate. It involves a minor surgical procedure that removes a small part of the vas deferens or blocks it another way. It may not be fully effective for 3 months after the operation (and occasionally even longer), during which time an alternative form of contraception should be used. The man is considered sterile when his semen contains no sperm. (You can easily have a test to check.) Overall failure rate of male sterilization is 0.1%-0.15%.

(iii) Sterilization for non-contraceptive reasons

  • Therapeutic sterilization: This is performed when a woman’s life or health is threatened by future pregnancy—for example, the removal of a damaged uterus. If there is a clear medical indication, sterilization in this situation is ethically justified as a necessary medical treatment, with the primary motivation being the preservation of health.
  • Eugenic sterilization: The eugenics movement of the first half of last century championed the sterilization of people not thought fit to contribute to the human gene pool. It received government support in many countries, including Australia. In some parts of the United States, laws were passed providing for compulsory sterilization of ‘misfits’ including rapists, drunkards, epileptics and the insane. While these laws have since been repealed, the idea that some people should not be allowed to reproduce is still voiced. There are reports of disabled women and girls being sterilized without their consent in Australia with some eugenic motivation.[100] Following Hurricane Katrina, Member of the Louisiana State Legislature John La Bruzzo proposed paying poor women US$1000 to be sterilized, to limit the numbers on welfare rolls.[101] While he said his plan would be voluntary and would include incentives for men (to avoid gender discrimination), it also included incentives for college-educated, higher-income people to have more children. “What I’m really studying is any and all possibilities that we can reduce the number of people that are going from generational welfare to generational welfare,” he said.

The idea behind eugenics—that only humans with certain preferred characteristics should be born—is opposed to the biblical teaching that all humans are made in the image of God and are therefore valuable, regardless of their personal capabilities.

  • Punitive sterilization: Punitive sterilization, such as castration, has been advocated as a punishment for criminals guilty of sexual crimes. Recently there has been discussion in a major medical journal regarding the pros and cons of surgical or chemical castration of convicted sex offenders. Those in favour (so long as the prisoner consents) mention the benefit offenders report from being released from sexual preoccupation, and being able to participate in psychological treatment programs they were previously too distracted to join. Those opposed question whether true consent is possible if the alternative is lifelong imprisonment, and also challenge whether it is ethical for doctors to act in the best interests of society rather than the best interests of their patients.[102]
  • Sterilization of the mentally disabled: Sterilization of the mentally disabled (usually of females) can be motivated by desire for contraception or to save the person involved from the distress associated with menstruation. This is a controversial topic that at times has had eugenic overtones (see above). In 2010, an Australian court considered the case of an 11-year-old girl, ‘Angela’, who had severe intellectual disability and seizures that were provoked by heavy menstruation despite her medication.

Discussion of how best to support the sexuality of a mentally disabled person is beyond the scope of this book, but should be multi-faceted and involve precautions to avoid abuse. Research consistently finds that rates of sexual assault of people with a disability are much higher than the general population. Despite evidence that approximately 20% of Australian women and 6% of men will experience sexual violence in their lifetime,[103] there is no standard national data collection that includes the experiences of women with a disability. A study of Victoria Police data indicates that just over a quarter of all sexual assault victims were identified as having a disability. Of this group, 130 (15.6%) had a psychiatric disability or mental health issue and 49 (5.9%) had an intellectual disability.[104] These data indicate that adults with a psychiatric and/or intellectual disability in particular are over-represented as victims of reported sexual assault, representing just 2.2% and 0.8% of the Australian population generally.[105] This would indicate a need for policy reform for those at risk of such abuse, rather than their sterilization.

Sterilization of the mentally disabled on grounds that the offspring would be disabled is not justified. We know that mentally retarded individuals will not necessarily give birth to retarded children, and discrimination on the grounds of ability is contrary to the biblical teaching that all individuals are made in the image of God and therefore deserving of respect.

To remove without consent someone’s ability to reproduce is a violation of human dignity. Such a procedure should be performed without consent only if there is a serious threat to the life of the person concerned, as in the case above. Due to variation in degrees of retardation and levels of competence, each case should be considered individually. The option of long-term reversible contraception such as Implanon or Depo-Provera (which may also stop bleeding) should be considered as an alternative.

h. Emergency contraception (the ‘morning-after pill’)

In Christian marriage, the couple should think about contraception in advance of needing it so that decisions can be made thoughtfully. Emergency contraception will not be needed very often. However, since by definition you will not be expecting to use it, it helps to understand how ‘emergency contraception’ works, just in case.

Traditionally, those hoping to prevent conception after having unprotected sex might have tried douching. It is still tried today, often with water and spermicide. This is not a reliable form of contraception. Neither is douching with Coca-Cola (another favourite). Sperm have been detected in cervical mucous on their way to the uterus within 90 seconds of ejaculation. Douching only reaches the vagina, so by the time it is done it is usually too late.

A more common occurrence these days is for general practitioners and pharmacists to be approached by women requesting the ‘morning-after pill’ (MAP). This usually follows condom malfunction or unprotected intercourse during the previous 24 hours, and has been promoted as form of ‘retrospective contraception’. The common label of ‘morning-after pill’ is misleading, as some types work up to 120 hours after unprotected sex. Our society regards use of emergency contraception (EC) as a responsible course to follow if an unplanned pregnancy is unwanted.

There are several forms of EC available. The first is a copper IUD inserted soon after intercourse. The others are pills, listed below. Effectiveness varies, but none are 100% effective.

(i) Copper IUD

When a copper IUD is inserted into the uterus immediately after intercourse, up to 5 days after ovulation, it is very effective in preventing pregnancy. If ovulation has occurred at the time of insertion, the copper IUD works mainly by blocking implantation.[106] If ovulation has not occurred at the time of inserting the IUD, it will act in a similar way to long-term use, which (as noted above) is primarily by toxicity for sperm but also involves effects after fertilization. Therefore this method is unethical regardless of when it is administered.

(ii) Levonorgestrel

It is not known exactly how levonorgestrel (Postinor-2, Levonelle, NorLevo, Plan B, Plan B One-Step, Next Choice) works in the emergency situation. If it is taken before the LH surge (which triggers ovulation), it will usually inhibit ovulation and probably thicken cervical mucus. If taken after ovulation, it is less clear. There is little evidence to suggest a direct anti-implantation effect. If it is not administered in time to block ovulation, it is likely to fail.[107]

It is difficult to be prescriptive about ethics when the exact method of action is unknown. There would be no doubt of the morality of using this medication if the woman were known to be pre-ovulatory in the monthly cycle at the time of use (see below), because there would be no egg available for fertilization. After ovulation there is no point in taking it, due to the side effects of the medication and the likelihood of failure. If there is an embryo in place at the time, it is likely to stay there.

(iii) Ulipristal acetate

Ulipristal acetate is a more recent morning-after pill, usually known by its brand name: ella, ellaOne. It blocks the action of the hormone progesterone. When taken immediately before ovulation is to occur, ella postpones follicular rupture (release of the egg). The likely primary mechanism of action is therefore inhibition or delay of ovulation; however, according to the manufacturer, alterations to the endometrium that may affect implantation may also contribute to efficacy.[108] The dose is one tablet taken as soon as possible, up to 120 hours (5 days) after unprotected intercourse. It is not available in all countries.

If ulipristal is taken before ovulation it would be an ethical choice, as no egg would be released and therefore no fertilization would occur. However, if taken after ovulation, it is possible (given the current state of knowledge) that if an embryo were created it would be unable to implant in the uterus. Ulipristal would therefore be an unethical choice. See below for how to determine the timing of ovulation in this situation.

For doctors

According to the manufacturer, ulipristal acetate is an orally active, synthetic progesterone agonist/antagonist. It reversibly blocks the progesterone receptor in its target tissues (uterus, cervix, ovaries, hypothalamus) and acts as a potent anti-progestational agent. Studies have shown that when compared with levonorgestrel, ulipristal was no less effective in preventing pregnancies when administered within 72 hours of unprotected intercourse, but was more effective when administered later (within 72-120 hours). Meta-analysis suggests that ulipristal may be more effective than levonorgestrel from day one and throughout the entire 5-day period following unprotected sexual intercourse.[109]

(iv) The combined hormone (Yuzpe) method

The Yuzpe method involves a high dose of a combined pill that contains both oestrogen and progesterone. When given within 72 hours of unprotected intercourse, if ovulation has not yet occurred it may be suppressed or delayed by the intervention. If ovulation has occurred, the Yuzpe method normally causes shedding of the endometrium and if an embryo already exists it will be lost in the menstrual flow.

Women who use the Yuzpe method are at risk of causing an early abortion if they are unaware of where they are in their ovulatory cycle at the time (which is usually the case). However, if they did know where they were in their cycle, they could take the medication to suppress or delay ovulation so that the egg would not be available for fertilization, and so reduce the likelihood of pregnancy. This would be a true pre-fertilization contraceptive effect.

(v) RU-486 (mifepristone)

RU-486 (mifepristone) was developed specifically to cause medical abortions. It is sometimes called the ‘morning-after pill’ but in fact it is not a contraceptive. Some authors have suggested that it should be used as an emergency contraceptive.[110]

Determining the timing of ovulation in the emergency setting

Pro-life doctors have developed a protocol that allows review of the hormone levels (oestrogen and progesterone) in the woman presenting after unprotected intercourse. These tests show where she is in her ovulatory cycle, which allows the doctor to determine whether she is in a potentially fertile phase and assess whether she really is at risk of pregnancy. As a result, doctors can reassure those women who are in one of the infertile phases that they do not need any ‘treatment’, and so will not be exposed to the significant side effects of these drugs. If she is in the period of possible fertility prior to ovulation, it is possible that one of the morning-after pill regimes may be able to delay ovulation long enough to prevent fertilization without harming a pregnancy if it has already begun. If ovulation has occurred or is imminent, emergency contraception could be operating by causing an abortion, and will therefore be unethical.[111] Note that there are contraindications to the use of some of these methods, which should be checked with a doctor before use.

In cases of rape

In the case of rape, care of the woman in crisis needs to be multi-dimensional, and this cannot be fully addressed in this book. The ovarian hormone tests mentioned above will give valuable information to the woman regarding her risk of pregnancy. There has been little research done on the effect of abortion after rape, but some studies suggest that women who continue a pregnancy following rape do better than those who abort.[112]

Heather Gemmen, who wrote about her experience of rape, describes her experience in the hospital that night.[113] Her doctor gave her a hormone tablet that, he said, “changes the environment of the uterus so the egg cannot implant”. After clarifying that the pill would stop an embryo from implanting, and that this represented early abortion, she was nevertheless encouraged to take it. She wrote, “Death does not seem so gruesome or final when you are holding it in your hand in the form of a tiny pink pill”.

A woman in this situation is incredibly vulnerable emotionally, and it is easy to see how she could be persuaded to act against her conscience. The immediate offer of non-abortifacient (non-abortion causing) contraception, if applicable, can avoid risking any further trauma resulting from her guilt about complicity in abortion. Such procedures attempt to delay ovulation beyond the time the rapist’s sperm would be able to survive, so reducing the chance of pregnancy. This is ethically appropriate, and it is important the woman involved is told so. (Read Heather’s inspiring story to see what happened next.)[114]

The chapter on abortion contains further discussion of what should be done in this situation. It should be noted that in the case of rape, it is accepted in orthodox Catholic theology that attempted postponement of ovulation by taking hormonal contraceptives is legitimate, as the goods of marriage do not exist in this circumstance (so they cannot be destroyed by the use of contraception).[115]

For doctors and pharmacists

Health professionals can find themselves in a difficult situation when a patient requests a type of contraceptive that the health professional thinks is unethical. Provision of emergency contraception can raise particularly difficult ethical questions for those health professionals who are expected to provide this legal alternative to patients who request it. It is especially stressful if the woman is extremely anxious (which is not unusual).

Some doctors have found it helpful to place a discreet sign in the waiting room advising patients before the consultation that only contraceptives acting before fertilization will be available. Few jurisdictions oppose doctors’ right of conscience on this issue. Pharmacists may find it more difficult, especially if they are not senior staff in the pharmacy. It may be possible to reach an agreement with other staff not to have to provide contraceptives that you oppose on moral grounds. At present in my state of NSW, there is no legal requirement for pharmacists to stock any particular therapeutic device or treatment. Check the legalities for your jurisdiction. Australian Pharmacist John Wilks has not stocked oral contraceptives or condoms for many years. He chooses not to stock the MAP on medical grounds, because it breaches his duty of care consistent with the Pharmaceutical Society of Australia’s Code of Ethics, principles 1.1 and 1.2.[116]

Regardless of your approach to emergency contraception and its provision, it is important to take this opportunity to sympathetically counsel the woman who presents. Apart from the protocol to assess fertilization risk (above), important issues to raise include the availability of support for the victims of rape or incest, and the need for future contraception so this situation does not rise again.

This is an opportunity for you to explore the woman’s (and possibly man’s) attitude towards keeping a pregnancy (either as the primary move or after possible EC failure), as it is possible that no-one else will raise this as a possibility. Being aware of support services for pregnant women in your area will allow you to provide practical assistance to those who initially see early abortion as their only choice, even if that is not what they really want.

Sometimes it is only when we take a stand that others start to think more carefully about their choices.


In summary, then, we have the following categorization of available contraceptives:

Ethically acceptable Caution needed (see text) Ethically unacceptable
  • Progestin-only injections (DMPA, NET-EN)
  • Implanon implant
  • Fertility awareness methods: natural family planning and lactation amenorrhoea method
  • Barrier methods: cap, condom, diaphragm, sponge, spermicide
  • Withdrawal method
  • Oral contraceptive pill
  • Progestin-only oral pill (mini-pill)
  • Combined injectable contraceptive
  • Combined vaginal ring
  • Combined patch
  • Abstinence
  • Sterilization
  • Emergency contraception (morning-after pills)
  • Jadelle, Norplant implant
  • Ormeloxifene
  • Intrauterine devices and systems (IUDs and IUSs)
  • Abortion (including RU-486)

We learn from this chapter that the easy availability of reversible contraception has reduced the tolerance for unplanned pregnancy. The societal expectation is now that failure of contraception, or even failure to use contraception, is appropriately dealt with by elective abortion. But is that what women really want?

  1. Modern science has demonstrated that acacia does indeed act as a spermicide, so it may have worked. The early history of contraception here has been adapted from JT Noonan, Contraception, Mentor-Omega Press, New York, 1965, pp. 23ff. This book is highly recommended reading for those interested in this topic. 
  2. This legislation was introduced by Augustus in response to the falling birth rate in the upper class: Lex Julia de maritandis ordinibus (18 BC) and Lex Papia Poppaea (9 AD). It disqualified the childless from high office and the right of inheritance. 
  3. Philo, The Special Laws 3.2.9. 
  4. Noonan, op. cit., pp. 74ff. 
  5. Noonan, op. cit., p. 77. 
  6. Clement of Alexandria, Pedagogus 
  7. This was the Christian philosophy as explained by the Greek philosopher Athenagoras in 177 AD. 
  8. Oral and anal sex, and probably coitus interruptus (which will be discussed later in this chapter). 
  9. Noonan, op. cit., pp. 103-4. 
  10. Noonan, op. cit., p. 151. 
  11. Augustine, Sermons 62.2. 
  12. Pelagius was a British monk (360-420 AD) who taught that salvation could be achieved by one’s good moral nature and that grace was unnecessary. He and Augustine argued about the nature of original sin. Pelagius was condemned as a heretic by the Councils of Carthage in 416 and 418. 
  13. Augustine, Marriage and Concupiscence 2.5.14. 
  14. Augustine, The Morals of the Manichees 18.65. 
  15. Augustine, Adulterous Marriages 2.12.12. 
  16. Augustine, The Good of Marriage 29.32. 
  17. Inherent in Augustine’s argument is the idea that the command to multiply no longer applies after the coming of Christ. This idea is elaborated below. 
  18. Noonan, op. cit., p. 209. 
  19. Thomas Aquinas, Summa Theologica, part II, in Noonan, op. cit., p. 291. 
  20. J Calvin, Institutes 2.8.42-3. 
  21. Noonan, op. cit., p. 423. 
  22. These arguments had been offered by Rev. Thomas Malthus in a 1798 publication where he warned that, without measures to restrict population growth, by 1900 food in England would feed only one third of the population. As the remedy, however, he advertised not contraception but abstention. 
  23. This argument had been recommended in an 1832 essay by Charles Knowlton, using utilitarian arguments. There is evidence that Sanger and Stopes were also motivated by eugenic aims to reduce the fertility of the genetically inferior. 
  24. Secretary General of the Anglican Consultative Council, ‘Resolution 15: The Life and Witness of the Christian Community—Marriage and Sex’, Resolution from the 1930 Lambeth Conference. 
  25. Encyclical of Pius XI, Casti Connubii: On Christian Marriage, Rome, 31 December 1930, paragraph 11. 
  26. KD Blanchard, ‘The gift of contraception: Calvin, Barth and a lost Protestant conversation’, Journal of the Society of Christian Ethics, vol. 27, no. 1, 2007, pp. 234-5. 
  27. RA Mohler Jr, in ‘Contraception: A Symposium’, First Things, December 1998, p. 24. 
  28. Encyclical of Paul VI, Humanae Vitae: On the Regulation of Birth, Rome, 25 July 1968, paragraph 11. 
  29. According to Humanae Vitae, natural family planning is permissible for Catholics (see below for explanation of this contraceptive method). Humanae Vitae is discussed in HOJ Brown, J Budziszewski, CJ Chaput, E Chevlen, SE Hinlicky, G Meilaender, P Turner, R Albert Mohler Jr, A Mosier and JE Smith, ‘Contraception: A Symposium’, op. cit., pp. 17-29. The position of Humanae Vitae was affirmed in 2008 in Dignitas Personae (‘The Dignity of a Person’). 
  30. Paul VI, op. cit., paragraph 13. 
  31. Paul VI, op. cit., paragraph 14. 
  32. K Barth, ‘Parents and Children’, in Church Dogmatics, vol. III.4, GW Bromiley and TF Torrance (eds), T and T Clark, London and New York, 2010, p. 269. 
  33. Secretary General of the Anglican Consultative Council, op. cit. 
  34. Barth, loc. cit. 
  35. ibid., p. 270. 
  36. See the discussion of the word ‘offspring’ in BK Waltke and CJ Fredricks, Genesis: A commentary, Zondervan, Grand Rapids, 2001, p. 93. 
  37. Noonan, op. cit., p. 73. 
  38. ibid. 
  39. Barth, op. cit., pp. 142-4. 
  40. C Ash, Marriage: Sex in the Service of God, IVP, Leicester, 2003, pp. 170ff. This passage contains a detailed critique of Barthian and Augustinian positions on marital procreation. 
  41. O O’Donovan, Resurrection and Moral Order, 2nd edn, Apollos, Leicester, 1994, p. 210. 
  42. JJ Davis, Evangelical Ethics, 3rd edn, P and R Publishing, Phillipsburg, 2004, p. 54. 
  43. See chapter 4. 
  44. See chapter 16. 
  45. S Hauerwas, The Hauerwas Reader, ed. J Berkman and M Cartwright, Duke University Press, London, 2001, p. 499. 
  46. R Clapp, Families at the Crossroads, IVP, Leicester, 1993, p. 136. 
  47. S Basten, Voluntary Childlessness and Being Childfree, The Future of Human Reproduction: Working Paper 5, St. John’s College, Oxford, and Vienna Institute of Demography, June 2009. 
  48. O O’Donovan, Marriage and Permanence, Grove Ethical Booklets, no. 26, Nottingham, 1978, p. 12, cited in Ash, op. cit., p. 179. 
  49. Blanchard, op. cit., p. 243. 
  50. Ash, op. cit., p. 175. 
  51. A Rosenfeld, The Second Genesis, Prentice-Hall, Englewood Cliffs, 1969, p. 108. 
  52. See the oral contraception pill section later in this chapter, and also appendix I. 
  53. It is sometimes explained in terms of conception being a ‘process’ that commences at fertilization and is not complete until implantation, with the pregnancy in place only after the ‘process’ is complete. 
  54. EC Hughes (ed.), Obstetric-Gynecologic Terminology, Committee on Terminology, American College of Obstetricians and Gynecologists, FA Davis, Philadelphia, 1972, p. 327. 
  55. As explained in chapter 2. For example, see R O’Rahilly and F Müller, Human Embryology and Teratology, 3rd edn, Wiley-Liss, New York, 2001, pp. 8, 87; and BM Carlson, Patten’s Foundations of Embryology, 6th edn, McGraw-Hill, New York, 1996, p. 3. 
  56. My informal research has elicited none. 
  57. See chapter 3. 
  58. For further discussion of this point, see ‘8. The problem of detection’ under ‘Common objections to the argument that human life begins at fertilization’ in chapter 2. 
  59. Unless indicated otherwise, all effectiveness rates are taken from J Trussell, ‘Contraceptive efficacy’, in R Hatcher, J Trussell, A Nelson, W Cates Jr, FH Stewart and D Kowal (eds), Contraceptive Technology, 19th rev. edn, Ardent Media, New York, 2007, pp. 747-826; rates for monthly injectables and cervical caps are from J Trussell, ‘Contraceptive failure in the United States’, Contraception, vol. 70, no. 2, August 2004, pp. 89-96; both as cited in World Health Organization (WHO) Department of Reproductive Health and Research and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Family Planning, appendix A, Knowledge for Health Project, CCP and WHO, Baltimore and Geneva, 2011, p. 319. 
  60. For discussion of the use of these medications for other purposes, see chapter 16. 
  61. Brand names for hormone contraceptives vary throughout the world. I have included a few examples of each type, but if you would like to check other brand names for hormonal contraceptives you can do so through the IPPF website’s directory: I do not endorse the content of this website overall, but the contraceptive directory is accurate and regularly updated. 
  62. See diagram 1: Female reproductive organs in chapter 2. 
  63. See also hormonal IUD (Mirena) under ‘c. Intrauterine devices’ below. 
  64. J Trussell, ‘Contraceptive efficacy’, loc. cit. 
  65. For further discussion of this issue, see appendix I. 
  66. J Guillebaud, ‘When do contraceptives work?’ Triple Helix, Summer 2003, pp. 12-13. 
  67. J Guillebaud, Contraception, 4th edn, Churchill Livingstone, Edinburgh, 2004, p. 112. 
  68. OEO Hotonu, Contraception: A pro-life guide, The Christian Institute, Newcastle on Tyne, 2005, p. 26. 
  69. A Edelman, MF Gallo, JT Jensen, MD Nichols and DA Grimes, ‘Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception’, Cochrane Database of Systematic Reviews, issue 3, 2005. 
  70. KL Gerschultz, GS Sucato, TR Hennon, PJ Murray and MA Gold, ‘Extended cycling of combined hormonal contraceptives in adolescents: Physician views and prescribing practices’, Journal of Adolescent Health, vol. 40, no. 2, February 2007, pp. 151-7. 
  71. Guillebaud, Contraception, op. cit., p. 13. 
  72. ibid. 
  73. D Shoupe and SL Kjos (eds), The Handbook of Contraception, Humana Press, Totowa, 2006, p. 67. 
  74. Organon Laboratories Limited, Cerazette home page, Organon Laboratories, Hertfordshire, 2010 (viewed 19 October 2011): 
  75. Hotonu, op. cit., p. 21. 
  76. HJ Bennink, ‘The pharmacokinetics and pharmacodynamics of Implanon, a single-rod etonogestrel contraceptive implant’, European Journal of Contraception and Reproductive Health Care, vol. 5, supp. 2, September 2000, pp. 12-20. 
  77. Hotonu, op. cit., p. 38. 
  78. Janssen Pharmaceuticals, Important Safety Information, Ortho Evra product information, Janssen Pharmaceuticals, Titusville, 2011 (viewed 19 October 2011): 
  79. Guillebaud, Contraception, op. cit., p. 271. 
  80. ibid. 
  81. Hotonu, op. cit., p. 16. 
  82. ME Ortiz, HB Croxatto and CW Bardin, ‘Mechanisms of action of intrauterine devices’, Obstetrical and Gynaecological Survey, vol. 51, no. 12, December 1996, pp. 42S-51S. 
  83. ME Ortiz and HB Croxatto, ‘Copper -T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action’, Contraception, vol. 75, no. 6, supplement, June 2007, pp. S16-30. 
  84. YC Smart, IS Fraser, RL Clancy, TK Roberts and AW Cripps, ‘Early pregnancy factor as a monitor for fertilization in women wearing intrauterine devices’, Fertility and Sterility, vol. 37, no. 2, February 1982, pp. 201-4, cited in JB Stanford and RT Mikolajczyk, ‘Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects’, American Journal of Obstetrics and Gynecology, vol. 187, no. 6, December 2002, pp. 1699-708. 
  85. L Videla-Riviero, JJ Etchepareborda and E Kesseru, ‘Early chorionic activity in women bearing inert IUD, copper IUD and levonorgestrel-releasing IUD’, Contraception, vol. 36, no. 2, August 1987, pp. 217-26. 
  86. I Barbosa, O Bakos, S Olsson, V Odlind and EDB Johansson, ‘Ovarian function during use of a levonorgestrel-releasing IUD’, Contraception, vol. 42, no. 1, July 1990, pp. 51-66. 
  87. Stanford and Mikolajczyk, loc. cit.; also see Ortiz and Croxatto, ‘Copper -T intrauterine device’, loc. cit. 
  88. See Paul VI, op. cit., paragraph 16. 
  89. An alternative argument is given to support the permissibility of NFP alone as a contraceptive. This is that by timing intercourse to coincide with a non-fertile period, it allows a couple to exercise birth control and at the same time respect the potential for procreation, as it is not present in a way to be violated. The marriage relationship is thought to be strengthened by abstinence in this instance. For elaboration of this argument, see JE Smith in ‘Contraception: A Symposium’, op. cit., pp. 27-9. 
  90. CMM Pyper and J Knight, ‘Fertility awareness methods of family planning: The physiological background, methodology and effectiveness of fertility awareness methods’, Journal of Family Planning and Reproductive Health Care, vol. 27, no. 2, April 2001, pp. 103-9. 
  91. Further information is available from the Australian Council of Natural Family Planning ( and FertilityCare centres ( See also The Natural Family Planning Information Site ( if you are in the United States or Fertility UK ( if you are in Britain. Many other organizations can be contacted via the internet. 
  92. J Trussell, ‘Contraceptive efficacy’, loc. cit. 
  93. J Schieszer, ‘Male birth control pill soon a reality’,, 1 October 2003  (viewed 19 October 2011): 
  94. Those interested in such developments can visit websites such as 
  95. Guillebaud, Contraception, op. cit., p. 44. 
  96. S Singh, D Wulf, R Hussain, A Bankole and G Sedgh, Abortion Worldwide, Guttmacher Institute, New York, 2009, p. 39. 
  97. A Chan, J Scott, A-M Nguyen and L Sage, Pregnancy Outcome in South Australia 2008, Pregnancy Outcome Unit, SA Health, Government of SA, Adelaide, 2009, p. 62. For a detailed discussion of abortion in other contexts, see chapter 7. 
  98. MM Singh, ‘Centchroman, a selective estrogen receptor modulator, as a contraceptive and for the management of hormone-related clinical disorders’, Medicinal Research Reviews, vol. 21, no. 4, July 2001, pp. 302-47. 
  99. S Hillis, PA Marchbanks, LR Tylor and HB Peterson, ‘Poststerilization regret: findings from the United States Collaborative Review of Sterilization’, Obstetrics and Gynaecology, vol. 93, no. 6, June 1999, p. 889-95. 
  100. L Dowse, ‘Moving forward or losing ground? The sterilization of women and girls with disabilities in Australia’, paper presented to the Disabled People’s International (DPI) World Summit, Winnipeg, 8-10 September 2004. 
  101. M Waller, ‘LaBruzzo considering plan to pay poor women ,000 to have tubes tied’, Times-Picayune, 23 September 2008. 
  102. D Grubin and A Beech, ‘Chemical castration for sex offenders’, British Medical Journal, vol. 340, no. 7744, 27 February 2010, c74; and subsequent correspondence. 
  103. Australian Bureau of Statistics (ABS), Personal Safety Survey Australia, ABS cat. no. 4906.0, reissued edn, ABS, Belconnen, 2006. 
  104. Statewide Steering Committee to Reduce Sexual Assault, Study of Reported Rapes in Victoria 2000-2003, summary research report, Office of Women’s Policy, Department for Victorian Communities, Melbourne, July 2006, p. 16. 
  105. Australian Institute of Health and Welfare (AIHW), Disability and Disability Services in Australia, AIHW cat. no. DIS 43, AIHW, Canberra, January 2006, p. 4. 
  106. Guillebaud, Contraception, op. cit., p. 460. 
  107. ibid. 
  108. HRA Pharma, Annex I: Summary of Product Characteristics, EllaOne manufacturer’s information, HRA Pharma, Paris, 2012, p. 6 (viewed 18 June 2012): 
  109. K McKeage and JD Croxtall, ‘Ulipristal acetate: A review of its use in emergency contraception’, Drugs, vol. 71, no. 7, 7 May 2011, pp. 935-45. 
  110. See chapter 7 for more information. 
  111. For details on the protocol of ovarian hormone testing and non-abortifacient emergency contraception, see N Tonti-Filippini and M Walsh, ‘Postcoital intervention: From fear of pregnancy to rape crisis’, National Catholic Bioethics Quarterly, vol. 4, no. 2, Summer 2004, pp. 275-88. 
  112. S Ewing, Women and Abortion: An evidence based review, Women’s Forum Australia, Brisbane, 2005, p. 12. 
  113. H Gemmen, Startling Beauty, Life Journey, Colorado Springs, 2004. 
  114. ibid. 
  115. Tonti-Filippini and Walsh, op. cit., p. 11. 
  116. For full details of Dr Wilks’s stance, see J Wilks, ‘Why this pharmacy does not sell the “morning-after” pill’,, 18 February 2004 (viewed 11 June 2012): 


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.


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 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



Specified medical condition



Serious handicap of fetus



Mental health of woman



Pre-existing psychiatric disorder



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






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]


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.


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


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.


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): 
  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): 
  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): 
  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’,, 24 July 2011 (viewed 6 November 2011): 
  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): 
  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. 

Screening in normal pregnancy

There was a time, now long gone, when pregnancy was a natural process that did not involve doctors and hospitals, ultrasounds and blood tests. Modern pregnancy is a technical affair, partly because we have discovered ways to keep the mother and baby safer during pregnancy and childbirth, and partly because we think we can control pregnancy to make sure we get the outcome we want. (It would be cynical to suggest it has anything to do with the fact that an obstetrician can be sued for malpractice up to 20 years after a birth.)

It is customary and right to want what is best for our offspring and to hope for a healthy child to be born. Love for the baby will usually mean that a mother will do her best to follow dietary and lifestyle advice to maximize her own health and the health of the child she is carrying. And by embracing modern medicine, we increase the likelihood of the best possible outcome through routine tests that aim to make sure we do all we can to keep mother and baby well. This is positive.

However, we now have an antenatal process that involves an increasing number of tests that not only check that the baby is healthy, but also that it is normal. These additional tests are slowly being adopted as part of routine antenatal care in industrialized countries, and there is no sign of the trend slowing down. This has occurred with virtually no community discussion as to whether this is the way we want pregnancy to be managed. Sometimes these tests for normality are done without the mother even realizing she is undergoing that kind of test. How can this be done, and what is the outcome of this change in direction?

Before we examine some of these more contentious issues, it is worth understanding the great benefits of good antenatal care in industrialized nations, and the nature of birth abnormalities. When we compare pregnancy outcomes for both mother and baby with those of developing nations, we soon realize that any improvement in obstetric care is a great blessing for which we should be truly thankful.

It can come as a shock to realize that, even today, pregnancy is not a risk-free enterprise. Over her lifetime, the risk of a woman dying as a result of pregnancy or childbirth is about 1 in 6 in the poorest parts of the world, compared to about 1 in 30,000 in northern Europe. Such a discrepancy poses a huge challenge to the United Nations in meeting the fifth Millennium Development Goal of reducing maternal mortality by 75% between 1990 and 2015.[1]

The global maternal mortality rate (MMR) decreased from 422 per 100,000 live births in 1980 to 320 in 1990 and 251 in 2008. More than 50% of all maternal deaths occurred in only 6 countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of the Congo).[2] Most deaths occurred around the time of the delivery.

However, this apparent improvement in MMR looks very different if we look at countries individually. In 2008, MMR was as follows:[3]


MMR in 2008

(per 100,000

live births)


MMR in 2008

(per 100,000

live births)











United States




Saudi Arabia










New Zealand




United Kingdom






Congenital abnormalities (birth defects)

There have always been children born with abnormalities. Research suggests that 2%-4% of all children born worldwide have major congenital abnormalities. In Australia, not all conditions at birth are reported and recorded, but national reports suggest that an average of 1.6% of all children born in Australia have major congenital abnormalities.[5] Common abnormalities include hypospadias (an abnormality of the penis where the urethra opens on the underside), trisomy 21 (Down syndrome) and neural tube defects such as spina bifida.[6] A higher rate of congenital anomalies has been reported for births among Indigenous women compared to non-Indigenous women (356 per 10,000 births compared to 308 per 10,000 births).[7] These numbers are not static. In about 60% of cases, the cause of the congenital anomaly is unknown and is probably multifactorial.[8]

Data is being collected more carefully now as governments try to reduce the incidence of newborns affected by congenital abnormalities. Some initiatives involve prevention, such as encouraging women who are attempting to get pregnant to take folic acid tablets to prevent neural tube defects and congenital heart defects, and introducing the mandatory fortification of bread flour with folic acid. These are welcome interventions.

But in cases where we have no preventative strategy, the focus is now on prenatal diagnosis; the trouble is that we can now screen for more problems than there are treatments. This has led to a much more troubling outcome where abortion has become the dominant ‘solution’ for these problems. Screening has now reached the point where even if we have do have a cure, it is still not enough; over 90% of pregnancies found to have abnormalities present proceed to termination. It seems as if the whole modern reproductive industry is aimed at making sure that only normal babies come to term.

What are we to do? Those couples who value human life from fertilization and who do not want to abort their child will need to become familiar with standard screening tests in pregnancy in order to decide which ones are desirable (to maximize health in the mother and baby) and which ones are not. If they are not prepared to terminate a pregnancy, they will have to ask whether there is any point in having tests to identify problems that can only be managed by termination.

Let’s look first at the standard antenatal tests and their purpose, before moving on to discuss genetic testing and screening. (This chapter is not intended to be a comprehensive guide to medical care in pregnancy.)

What are the standard tests for a normal pregnancy?

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has a standard protocol for antenatal testing.[9] The initial tests are recommended before the woman becomes pregnant, because some intervention is best done at that stage. All of these recommended tests aim to improve outcomes for the mother and baby.

1. Pre-pregnancy clinical assessment

a. Rubella (German measles) immunity status

Rubella is a highly contagious, though usually mild, viral disease. Those affected may have a transient rash and enlarged lymph nodes (and occasionally more serious problems), but half the people affected have no symptoms at all; it is hard to know who has had it. Consequently, it is necessary to confirm previous infection by looking for protective levels of antibodies in the blood.[10] Although it is a mild illness when it occurs in adults, if a woman contracts a rubella infection in the first 8-10 weeks of pregnancy, it can infect the baby, resulting in congenital rubella syndrome (CRS) in 90% of affected pregnancies.[11] CRS causes multiple defects in the baby, including intellectual disabilities, cataracts, deafness, heart abnormalities, restricted growth and inflammatory lesions of the brain, liver, lungs and bone marrow. Infection of the baby after 8 weeks of pregnancy commonly results in deafness and progressive blindness.[12] It is rare for the baby to be damaged if the infection occurs after 10 weeks of pregnancy, although it has been reported after 20 weeks of gestation.[13]

There is no treatment for the disease. Prevention is the best strategy, and since the rubella vaccine was introduced, rubella infection (including congenital rubella) has fallen by 99.6%.[14] It is recommended that women of child-bearing age who are found to have no evidence of previous infection should be vaccinated (and avoid conception for one month after the injection), and be checked 8 weeks after vaccination to make sure they are covered. All women are advised to check their rubella levels before every planned pregnancy, regardless of any previous results.[15] Even when a pregnant woman has been vaccinated, it is still best to avoid people who have had rubella or been exposed to it, for 6 weeks from the time of the exposure.[16]

b. Varicella (chicken pox) immunity status

This test is recommended if the woman’s immunity status is unknown and she does not know if she has had chicken pox. Varicella is another highly contagious viral infection. Once you’ve had it, it may reactivate later as herpes zoster (shingles). Varicella is usually a mild childhood disease, but in adults or in any person with lowered immunity it becomes a severe disease and may even be fatal. Varicella infection in pregnancy may result in congenital varicella syndrome, which can cause skin scarring, limb defects, eye abnormalities and malformations of the baby’s neurological system. Unlike rubella (which is a risk only in the first trimester), there is a greater risk of the baby being damaged if maternal infection occurs in the second trimester, while intrauterine exposure during the third trimester poses the greatest risk of developing shingles in infancy.[17] Because of these serious potential dangers for the baby, a non-immune mother should be vaccinated before pregnancy to avoid infection during pregnancy.[18]

c. Cervical (Pap) smear

The cervical or Pap smear—named after Dr George Papanicolaou—is used to check for changes in the cervix (the neck of the womb) at the top of the vagina.[19] This is done to look for abnormalities that might develop into cervical cancer in the future. It is recommended that all pregnant women be offered a cervical smear if they have not had one performed within the previous two years (for women with no history of abnormal changes), or within the time specified for follow up (for women who have had abnormal changes in the past). If abnormal changes are found at screening, further tests will be done to see if treatment is needed.[20]

2. The first antenatal visit in pregnancy

If the tests listed above have not been done just before the pregnancy, they should be done at the first antenatal visit (although vaccination should be postponed until after delivery if women are found to have had no previous exposure.)[21]

The following investigations are recommended as screening tests, to see if there are any relevant medical problems the doctor needs to know about to keep the mother and baby safe. By detecting disease before it causes symptoms, treatment can be started early to avoid, or minimize, complications for either mother or child. The doctor will take a detailed history and examine the mother at this time, and extra tests may be considered depending on the woman’s medical history, her family history and whether she has been exposed to other infections that could cause harm to the baby. Most of the extra tests are blood tests and all are recommended to make the pregnancy safer.

In its principles of screening, the World Health Organization (WHO) expects that tests used for screening will: detect a disease when it is still asymptomatic; have a high sensitivity and specificity (few false positives and false negatives);[22] have an available treatment for the condition and evidence of an improved outcome with treatment; have acceptability among the general population; and be cost efficient.[23] The tests in this section all achieve these screening goals.

a. Full blood count

A full blood count (FBC)[24] is a very common test in medicine and it assesses the general health of the mother. An FBC not only tests for abnormalities of the blood, but it can also give an indication of disease present in other organs. It is repeated at 28 weeks of pregnancy. A full blood count includes the following:

  • Measurement of haemoglobin (which carries oxygen) in the blood. If anaemia is detected, further investigation is warranted to discover the cause. Anaemia can make women tired and faint, and can put them at increased risk of infection and maternal mortality. Iron deficiency anaemia in pregnancyis a risk factor for preterm delivery and subsequent low birthweight, and possibly for inferior neonatal health. (Iron supplementation for pregnant women who are not iron deficient is controversial.)[25]
  • Close analysis of red blood cells; this also helps to diagnose the cause of anaemia, if it is present.
  • Measurement of white blood cells (WBCs). These are an important part of the body’s immune system, which fights infection.
  • Measurement of platelets in the blood. Platelets are part of the blood clotting system of the body.[26]

b. Blood group and antibody screen

This screening determines the mother’s blood group and detects the presence of antibodies. This is done at the first visit for all women, and then again at 28 weeks for Rhesus (Rh) negative women only, to check for ‘public antibodies’.[27] It is used, in particular, to identify those that have potential for causing a reaction in the baby’s blood at birth, known as haemolytic disease of the newborn (HDN).[28] Commonly, the mother is stimulated to produce these antibodies through blood transfusion, bleeding associated with delivery, trauma, miscarriage, induced abortion, ectopic pregnancy or invasive obstetric procedures. Any fetal red blood cells that cross the placenta into the mother’s bloodstream and are incompatible with the maternal blood group have the potential to stimulate the mother to produce antibodies against the baby’s red blood cells. These antibodies can then cross the placenta into the baby’s bloodstream and begin to attack the baby’s red blood cells, which can result in the fetus becoming anaemic, with potentially disastrous consequences such as neurologic injury or death. It is most commonly an issue of incompatibility between the (Rh negative) mother’s blood and the (Rh positive) baby’s. In order to prevent the development of these destructive antibodies in the mother, Rh-negative women may require the administration of RhD-Ig antibodies both during pregnancy and after delivery.[29]

c. Syphilis serology

Syphilis is an infectious disease caused by the bacterium treponema pallidum. It is a treatable disease primarily transmitted through direct sexual contact, although it can also be transmitted from mother to child via the placenta during pregnancy and during childbirth. Pregnant women with untreated early syphilis can transmit the infection to their baby, resulting in miscarriage, stillbirth (25% of pregnancies), neonatal death (14% of pregnancies), premature birth, low birth weight or congenitally infected infants.[30]

All women should be tested once for syphilis during the first trimester of each pregnancy. Women at risk of acquiring (or reacquiring) syphilis should have a further test in the third trimester (preferably at 28-30 weeks) and at delivery. Untreated maternal infection in the first trimester is more likely to affect the baby. The infected mother can be treated with antibiotics appropriate to the stage of syphilis infection and thus avoid effects on the baby.[31]

d. Midstream urine (MSU)

Due to the body changes that occur during pregnancy, up to 10% of pregnant women develop bacteria in the urine. This can be confirmed in urine specimens. The primary complication of this condition is cystitis (bladder infection). If left untreated, this may cause an infection of the kidneys (pyelonephritis) in 25%-30% of cases.[32] There is an association between pyelonephritis and low birth weight, prematurity and death in the baby.[33] Antibiotic treatment can significantly reduce the risk of these complications.[34]

e. Human immunodeficiency virus (HIV)

The human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS) by infecting and damaging helper T cells, which are an important part of the body’s defences against infection. Internationally, HIV/AIDS remains a leading cause of illness and death in pregnancy. Mother-to-child transmission is the most common cause of HIV infection in children worldwide. Infection can occur during pregnancy, during labour and delivery, and during breastfeeding, and it is almost entirely preventable. Treatment of the mother through medication (antiretroviral therapy), delivery by caesarean section, and the avoidance of breastfeeding reduces the rate of transmission to the child from around up to 45% to less than 5%.[35]

The Centers for Disease Control and Prevention (CDC) in the United States recommend that HIV testing be part of the routine screening for all pregnant women because reproductive-aged women make up the fastest-growing group with new HIV infections, usually acquired through sexual contact. The recommendation is for testing at the beginning of pregnancy and again at 28 weeks, regardless of perceived risk.[36] Screening for HIV is not routine in all Australian states, despite the recommendations of both the national HIV testing policy and RANZCOG that all pregnant women should be offered HIV screening at the first antenatal visit.[37] Informed consent ideally should be obtained from the woman prior to appropriate counselling and testing.[38]

f. Hepatitis B serology

Hepatitis B (HBV) is also a blood-borne viral infection, and is symptomatic in 30%-50% of adults.[39] There are more than 350 million HBV carriers worldwide, of whom one million die annually from liver disease.[40] Mothers with chronic infection (carriers) have higher rates of preterm deliveries, premature rupture of membranes, placental abruption, labour induction and caesarean deliveries, and there is a greater risk of death, congenital malformations and low birth weight in their newborns.[41]

It is critical to identify HBV carriers because of the opportunity to provide almost complete protection against infection to the baby. Transmission of HBV from infected mother to newborn usually occurs at, or around, the time of birth. Around 90% of babies infected as newborns, although usually remaining asymptomatic, develop chronic HBV infection and are capable of transmitting the disease for years, or for life. Significantly, more than 25% of these infants develop chronic active hepatitis B and up to 25% die prematurely. Prevention of transmission from a carrier mother to her child can be achieved by adjusting labour management (no fetal scalp electrode, no fetal blood sampling), routinely giving newborns immunoglobulin as soon as possible after birth, and beginning a course of vaccination.[42]

g. Hepatitis C serology

As with hepatitis B infection, infection with hepatitis C virus (HCV) has implications for both mother’s and baby’s health. Chronic infection can result in the development of liver cirrhosis, or liver cancer, later in life.[43] The risk of an infected mother passing on hepatitis C to her baby during pregnancy and birth is related to the amount of virus in her blood. At present no drug therapies can be recommended to reduce the risk of mother-to-child transmission. Unlike HBV infection, no specific intervention at the time of delivery has been shown to reduce the risk of transmission to the baby.[44]

Advice varies regarding whether all pregnant women should have hepatitis C screening in pregnancy.[45]

h. Routine antenatal ultrasound

The place of ultrasound is controversial.[46] In Australia, it is recommended that all women be offered an obstetric ultrasound prior to 20 weeks in order to facilitate a safe delivery. This replaces the x-ray that used to be done (x-rays can be dangerous for the unborn).

During the first trimester—defined as the first 13 weeks of pregnancy—an ultrasound is often performed between 8-11 weeks gestation to check how many weeks pregnant the woman is, usually measuring crown-rump length (CRL). It is also used to check for placental position, multiple pregnancy and the baby’s growth and development.[47] The main aim of these observations is to make sure that the baby will be born without problems and, as such, it is a reasonable thing to do (for example, sometimes there may be reason why a caesarean is safer than a vaginal delivery).

Note that we are discussing routine antenatal screening here, which should be done when everything appears to be normal. If a specific problem is identified, the benefit versus risk ratio changes, and it may be safest for extra ultrasounds to be done to check that the baby is safe.

However, in their guidelines on routine ultrasound in low-risk pregnancy, the American College of Obstetricians and Gynecologists (ACOG) concludes:

In a population of women with low-risk pregnancies, neither a reduction in perinatal morbidity (harm to babies around the time of birth) and mortality (death) nor a lower rate of unnecessary interventions can be expected from routine diagnostic ultrasound. Thus ultrasound should be performed for specific indications in low-risk pregnancy.[48]

Current research suggests that screening by ultrasound in early pregnancy improves the early detection of multiple pregnancies and improves estimates of how many weeks pregnant the woman is, but does not reduce adverse outcomes for babies.[49]

Other ways in which ultrasound is used are documented below.

i. Gestational diabetes (GDM)

It is recommended that all pregnant women be screened for gestational diabetes (diabetes of pregnancy).[50] Blood screening is generally performed at 26-28 weeks of gestation, or at any stage if symptoms develop. The Glucose Challenge Test (GCT) is performed, followed by the Fasting Glucose Tolerance Test if the GCT is abnormal.[51]

Primary outcomes of GDM include serious perinatal complications (such as death, shoulder dystocia, bone fracture and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labour, caesarean birth, and maternal anxiety and depression. Treatment of GDM reduces serious perinatal morbidity and may also improve the woman’s health-related quality of life.[52]

j. Group B streptococcal disease (GBS)

GBS bacteria are recognized as a major cause of serious newborn infection. About one in 2000 newborn babies have GBS bacterial infections, usually presenting at birth or within 24-48 hours of birth. The baby contracts the infection from the asymptomatic mother during labour and delivery.[53] It is recommended that prenatal screening be performed at 35-37 weeks of gestation.[54] Preventative antibiotics are commonly given to ‘at risk’ women during labour to reduce the incidence of this disease.[55]

k. Other tests

Other tests that can be considered for women who have risk factors, but which are not included in routine screening, include:

  • testing for vitamin D deficiency
  • screening for abnormalities of haemoglobin, such as thalassaemia
  • checking blood for exposure to cytomegalovirus (CMV) and toxoplasmosis viral infections
  • checking for chlamydia infection
  • testing thyroid function.


All the tests listed above are recommended in a normal pregnancy to maximize health outcomes for mother and child. As a result of these tests:

  • treating the infection can prevent intrauterine infection (syphilis)
  • immunization can avoid the infection (rubella)
  • treating the infection can prevent complications (urinary tract infection)
  • treating the deficit can prevent complications (anaemia)
  • changing aspects of care can avoid infection of the baby (HBV).

There are no ethical problems with this approach. It is an appropriate use of medical knowledge to identify and manage any health problems before they have a negative impact on the pregnancy. These screening tests meet the requirements of the WHO guidelines.

Prenatal genetic testing

In a world where we are used to being in control of all areas of our lives, there have been moves to influence pregnancy outcomes to make sure we have perfect babies. But there’s a problem: there is no test that guarantees a healthy, normal baby.

Screening during pregnancy is done to assess the risk factors associated with having a baby with a chromosomal (genetic) or structural abnormality. Particularly if a woman is over 35 years old or has a family history of a genetic disease (i.e. one that is passed down through families), she may seek or be offered prenatal genetic testing for the baby.

Prenatal screening early in the pregnancy can sometimes be presented to women as routine, rather than as a choice (which in fact it is). Some doctors may not explain the screening fully because they feel uncomfortable asking women what they will do if the baby has an abnormality (e.g. “Do you want to terminate the pregnancy?”), while many doctors think early testing is beneficial as it allows couples with affected pregnancies to have more time to decide what to do. Research has shown, though, that many couples are not aware of the purpose for screening and its limitations, and so are unprepared when they receive bad news about the baby.[56]

All screening tests have limitations. They do not definitely show whether a baby will have a problem, nor do they identify every pregnancy that does have a problem (i.e. they can give a false negative test result); and they may identify an unaffected pregnancy as being at risk when in fact there isn’t a problem (i.e. they can give a false positive test result).[57] Most babies assessed as having an increased risk will be normal and healthy.[58] These are not precise tests.

Another concern with this testing is that we can test for a lot more problems than we have treatments, and often the only way to ‘solve’ the problem of an abnormality is termination of the pregnancy.[59] Genetic testing should always be preceded by counselling; this allows the parents to decide which tests, if any, are best for mother and child. Different tests are done depending on the stage of the pregnancy.

I do not want to imply that all women walk ignorantly into prenatal screening without any idea of what they are doing. For some it is an active decision. Connie, who has a family history of a bleeding disorder, said: It’s easy to say you shouldn’t screen if your family isn’t affected by genetic disease, but if you are, why would you leave something like this completely to chance? If you think this world is all there is, it’s a completely understandable choice.

One test is an exception, in that it claims to give a definite result—the newly developed test that determines the fetal gender as early as 7 weeks (though it is more reliable later on). This test analyses DNA found in the mother’s blood and may be used to identify gender-linked genetic disorders, in order to terminate affected pregnancies early.[60]

Once a risk is identified with these tests, only affected couples are offered further diagnostic tests, because the diagnosis of problems involves tests that carry a risk of miscarriage even if the baby is completely normal. Counselling should be offered here, too. If an abnormality is diagnosed, a couple needs time to consider the diagnosis and make decisions. The tests may be used to plan the management of the pregnancy and delivery, to prepare for the care of a child with special needs, to plan for the adoption of the baby, or to enable parents to decide whether they want to continue with the pregnancy.[61]

The WHO’s principles of screening should be followed for these screening tests as well.

Let’s see how these tests measure up. A discussion of the ethics of these tests will follow an outline of what is involved.[62]

1. First trimester

a. Obstetric first-trimester ultrasound scan

As explained above, RANZCOG recommends that all women should be offered an obstetric ultrasound before 20 weeks of gestation to check that the baby will be born without problems. This is an ethical and responsible thing to do within our current technological abilities, but it is not what is being discussed here. Because the best time to date the pregnancy and check the number of babies is between 8-12 weeks, a first-trimester scan is often done for these reasons. But a practice has developed where other features of the baby may be examined at the same time, to look for abnormalities.

b. Nuchal translucency (NT) screening test

This is an ultrasound that examines a fluid-filled space at the back of a baby’s neck (described as nuchal translucency) and measures its depth. This test is normally carried out between 11½-13½ weeks. Marketing claims the test finds “all chromosome anomalies”, especially trisomies 13, 18 and 21 (Down syndrome).[63] Trisomies 13 and 18 are usually associated with structural anomalies found at the morphology scan (18-20 weeks).

The NT test examines the collection of fluid within the skin at the back of the fetal neck observed between 10-14 weeks gestation. The NT peaks at 12-13 weeks and often disappears by 15 weeks. An increased NT (greater than 3 mm at 10-12 weeks) was first shown to be associated with Down syndrome in 1989.[64] Using a standardized protocol by appropriately trained staff, the detection rate for Down syndrome is up to 82% (being the probability of a probability). But there is a 1 in 20 chance that you will get a false positive result—that is, that the test will indicate a risk of Down syndrome when in fact the baby is normal (there is always a risk of Down syndrome until a direct gene test proves otherwise).[65] This can be pretty stressful, as it cannot be confirmed either way at this stage of the pregnancy. Ultrasound scanning is a user-dependent test, and a review of NT scan operators found that 45% of them were not performing it accurately.[66]

If the NT scan is performed alone without a blood test (see below), about 75% of babies who have Down syndrome will receive an increased risk result, so about 25% of Down syndrome babies will be missed. A 2005 study suggested that NT is insufficiently effective to justify doing it alone.[67]

Some studies show that pregnant women in industrialized countries expect to have the NT scan routinely, often with little understanding of what it means.[68]

c. First-trimester serum screening (FTSS)

In addition to ultrasound examination, blood tests can be used in the first trimester to identify babies with an increased likelihood of having a chromosomal or structural abnormality. (These tests are not always available and may only be done in conjunction with the NT scan.) The levels of specific proteins in the mother’s blood are measured.[69] These test results are combined with the result of the NT scan and the mother’s age to provide information about the risk of chromosomal abnormalities.[70] They can also give the doctor information about increased risk of obstetric complications.[71]

For chromosomal anomalies, a low risk is considered to be less than 1 in 300, however the risk is still there; ‘low risk’ should not be confused with ‘no risk’. About 5% of the women who have this test (1 in 20) as well as the NT scan will receive an increased risk result, but it is important to realize that most of these babies will not have a problem with their chromosomes.[72]

Other techniques to detect chromosomal abnormalities that have been recommended, but are not routine, include the ultrasound examination of the nasal bone and measurement of blood flow in the heart and the liver (for increased detection of Down syndrome).[73]

In October 2011, a new blood test was released that checks fetal DNA in the mother’s blood to detect Down syndrome. A published study indicates this test has a lower false negative rate than previously available tests (it picked up 98.6% of children with Down syndrome in the study), and a false positive rate of only 0.2% (it gave a result of Down syndrome for 0.2% of the children who were normal).[74] The test’s authors see this as an advantage as it means fewer women will need to have the invasive tests (see below) that currently are required to definitely diagnose the syndrome. The test can be used as early as 10 weeks into a pregnancy and will cost about US$1900, although it will be considerably less if health insurers decide to cover it. At the time of writing, it has not been approved by the FDA.

2. Second trimester

a. Second-trimester screening scan/fetal anomaly ultrasound/morphology scan

The second-trimester screening ultrasound, usually performed between 18-20 weeks gestation, is a major tool used to screen for abnormalities in the baby. As it is not invasive, it carries no added risk of miscarriage.

This scan is used primarily for diagnosing fetal structural anomalies such as neural tube defects (abnormalities of the spinal cord or brain) and cardiac, gastrointestinal, musculoskeletal, urinary tract and central nervous system defects in the second trimester.[75]

Scanning has become a rite of passage for pregnant women in most developed countries. In Australia, it is estimated that 99% of babies are scanned at least once in pregnancy, usually as a routine prenatal ultrasound at 4-5 months. In the United States, where this cost is borne privately or by an insurer, around 70% of pregnant women have a scan, and in European countries it is estimated that 98% of pregnant women have an ultrasound, usually once in each trimester (third) of pregnancy.[76]

It’s worth asking whether the main reason scans are scheduled is to allow parents a last-minute check to see if there is anything wrong with the baby, so that if they decide to terminate the pregnancy, they can do so before the 20-22 week cut-off (depending on your country) when it will need to be registered formally as a birth.

Some people are concerned about the frequency with which ultrasound is being used in pregnancy. An American study—looking at ultrasound operators’ knowledge regarding safety aspects of diagnosticultrasound during pregnancy—found that ultrasound end usersare poorly informed about the safety issues of using ultrasound during pregnancy.[77] Choices in medicine should balance risk and benefit. A review paper examining the use of ultrasound in pregnancy found that:

Routine ultrasound in early pregnancy appears to enable better gestational age assessment, earlier detection of multiple pregnancies and earlier detection of clinically unsuspected fetal malformation at a time when termination of pregnancy is possible. However, the benefits for other substantive outcomes are less clear.[78]

This ultrasound should be distinguished from the commercial 3D and 4D entertainment ultrasounds, which are currently not recommended either.[79]

Neural tube defects occur in about one in 800 babies. The risk is increased if there is a family history of neural tube defects, or the mother has insulin-dependent diabetes or is taking medicine for epilepsy. The most common types are anencephaly (the brain is undeveloped and the baby cannot survive long after birth) and spina bifida (an opening on the baby’s spine that exposes the spinal cord and can cause paralysis and other problems.)

Surgery during pregnancy to cure spina bifida was first performed successfully in 1998. Mrs Kipfmiller was 23 weeks pregnant when surgeons lifted her son, Noah, out of her womb to close the opening over the spinal cord.[80] A 2011 study showed that spina bifida babies who are operated on in the womb have better outcomes than babies operated on after birth.[81] However, the mothers don’t do as well. Research is progressing to find a less invasive way to correct the abnormality.[82]

b. Second-trimester blood screening

The second-trimester blood screening test is usually done at the 15-18 week stage. It involves the measurement of three special proteins produced during pregnancy, and is sometimes known as the ‘triple test’ or, if an extra one is measured, the ‘quadruple (quad) test’.[83] It is also called the ‘maternal serum test’, or, as one brochure described it, “a blood test to determine the risk of certain problems in your pregnancy”. No wonder people are unclear about the purpose of these tests.

This test is not diagnostic—that is, it does not identify the presence of specific conditions but it indicates if there is an increased likelihood of them. An increased risk means that the test result gives you a risk of greater than 1 in 300. A reduced risk means there is less than a 1 in 300 chance of a birth defect.

The levels of the proteins in the blood, combined with the mother’s age and other factors, can allow the doctor to estimate the risk of the baby having a problem with a chromosomal abnormality (the wrong number of chromosomes, for example) or having a neural tube defect (problems with the development of the spine [spina bifida] or brain [anencephaly]).

Every pregnant woman faces the possibility of having a baby with a chromosomal problem or a neural tube defect. This blood test tries to estimate that risk more clearly. Most babies with a neural tube defect will be identified using this blood test alone. Maternal blood screening plus the 19-week ultrasound can identify spina bifida in 95% of cases and anencephaly in 100% of cases.

About 5% of tests will give an increased risk result, and most of these babies will not have a chromosome problem. Down syndrome occurs in about one in every 700 babies. About 60% of babies who have Down syndrome will have an abnormal result, so about 40% of them will be missed using this test alone. There also are other birth defects that will not be detected using these tests.[84]

Evaluating these tests

Although it would seem reasonable to expect that using both the first- and second-trimester screening tests would increase the chances of detecting a fetal abnormality, this is not recommended; the false positive rate increases, making it more likely that the mother will be offered more invasive diagnostic procedures, thereby increasing the risk of the spontaneous loss of an unaffected (normal) baby.

Confused? I should think so.[85] So let’s compare these second-trimester screening tests with the WHO guidelines for such tests (above).

  • Can they detect disease in the asymptomatic stage? Yes and no, although the baby will continue to survive in the womb with most abnormalities.
  • Do the tests have high sensitivity and specificity? If there is such a test, it isn’t being used here! There are so many false negatives and false positives, I am surprised these tests are used so widely.[86]
  • Are there available treatments for the conditions? For some, yes. Spina bifida can be treated with surgery while the baby is still in the mother’s womb, and other problems can be treated after birth; these things are worth identifying so that what can be done is done. Sometimes it means the doctor will monitor the pregnancy more carefully, but for most problems this is not the case; hence the association with abortion. In my experience, abortion is now sometimes chosen even for curable problems. I have a paediatrician friend who says she hasn’t seen a case of club foot (which may not even need surgery for correction) in at least 20 years. (There are regional variations.)
  • Is there evidence of improved outcome with treatment? If babies are treated and not aborted, then usually, yes.
  • Are the tests acceptable to the population? Who knows? This program of weeding out the less-than-perfect babies has not been widely debated in our community and, as already mentioned, many of the women presenting for tests don’t realize what they are for.
  • Are they cost efficient? Does it save money to abort the abnormal babies? A 1992 study in the United Kingdom concluded that the cost of antenatal screening to ‘avoid’ the birth of one baby with Down syndrome was £38,000, but the cost of lifetime care was estimated at £120,000. The study concluded that the screening was therefore “cost effective”, and recommended that screening be made available throughout the country.[87] In 2007, an Australian paper quoted three studies that came to a similar conclusion.[88] And in an article in Nature magazine, the head of Stanford’s Center for Law and Biosciences, Hank Greely, said that he estimates the number of genetic tests performed on unborn babies in the United States will jump within 5 years from the current 100,000 to over 3 million, and that abortions will be viewed as a way to prevent money being spent on “high-cost children”—because who really wants “to bring a child into the world who will suffer and cause their family undue burden and emotional and financial hardship?”[89]

According to the WHO screening guidelines then, these tests should not be used as screening tools. They give unreliable results for conditions we cannot cure, and so they have normalized the termination of pregnancy when babies are not ‘perfect’ enough. The whole point of screening is to improve the health of the population; instead, this screening promotes eugenics.

Prenatal diagnostic tests

Prenatal diagnostic testing gives parents reliable information about whether their baby has a genetic problem. While everyone hopes for a healthy baby, sometimes there are serious problems with physical or mental development. Women who have been shown to be at increased risk of having a baby with a fetal abnormality are offered diagnostic testing. It is important that the parents receive counselling before deciding whether they want this test. Their decision may be influenced by concerns about the risk of miscarriage (caused by the test), not wanting to know prior to the birth whether there is a problem, and whether termination of the pregnancy is acceptable to the family.[90] Even if parents receive counselling, it’s not always easy. Gail remembers: It was a hard decision because the risk of miscarriage was the same as the risk of Down syndrome. If I had a miscarriage when there was nothing wrong with the baby, it would have been a terrible result. Research shows that women undergoing tests like amniocentesis often feel ambivalent about the test, and that counselling can help to clarify their decision-making.[91]

Both chorionic villus sampling (CVS) and amniocentesis (discussed further below) are invasive sampling procedures. They both collect cells that are used for chromosome analysis or, in specific cases, for DNA or biochemical analysis, to diagnose a specific genetic condition. Non-invasive genetic testing is under development, such as the maternal blood tests that look at fetal DNA (see above).[92]

Those who consider undergoing these tests should seek specialist counselling from a genetics service. This will provide the information they need to decide whether they want to go ahead, and support them as they consider what is involved. The Centre for Genetics Education gives reasons for seeking specialist counselling, which include:

  • there is a family history of genetic disease (a disease that runs in the family) and a couple is worried that the baby will develop the condition
  • a previous child has a serious medical problem
  • the mother is in her mid-thirties or older
  • the couple are blood relatives
  • the prenatal screening tests have given an increased risk result.[93]

In a small number of cases, the three tests mentioned below will indicate that the baby has, or will develop, a problem. This is obviously a devastating event for parents.[94] While you might think that counselling would be mandatory in each stage of this process, in many centres it is not.

1. Chorionic villus sampling (CVS)

Chorionic villus sampling involves the collection of tissue from the chorionic villus, which is the substance lining the uterus that develops into the placenta. The cells of the chorion are similar to the baby’s cells, so by taking a sample the baby’s genetic make-up can be examined. A fine needle is inserted through the abdominal wall or, less commonly, via the vagina. Continuous ultrasound monitoring is used to guide the operator so that the baby is protected. CVS is usually performed between 11-13 weeks gestation. However, there is a 1% risk it will not be accurate because of contamination of the sample with maternal cells, or because of the placenta cells being slightly different from the baby’s. In these cases, it may need to be repeated. Complications associated with CVS include cramping, vaginal bleeding and a <1% risk of miscarriage.[95] Its role in the subsequent development of preeclampsia (a serious, potentially life-threatening condition developing in late pregnancy, characterized by a sudden rise in blood pressure) is still being debated.[96] If CVS is performed prior to 10 weeks gestation, there is a risk of procedure-related limb defects.[97]

CVS is a diagnostic test, so it can indicate reliably whether or not the baby has certain problems, but it does not check for all possible diseases.

2. Amniocentesis

Amniocentesis involves the collection of a small sample (around 15 ml) of the amniotic fluid around the fetus using a fine needle and ultrasound guidance. From this fluid, fetal cells are extracted and then grown. The procedure is usually performed at 15-20 weeks gestation and is associated with a 1% miscarriage risk. Early amniocentesis (performed between 9-14 weeks gestation) is not safe.[98] As with CVS, amniocentesis can give a definite result for some, but not all, genetic abnormalities in the baby.

Hospital ethicist Robert Orr tells the sad story of a couple who decided to abort their 20-week fetus after Down syndrome had been diagnosed by amniocentesis. The baby was born alive and pronounced dead sixteen minutes later. Nurses reported that the father examined the baby closely and said, I thought he was going to be abnormal.[99]

Due to the high rate of false positive results for the earlier tests, many women undergoing amniocentesis and CVS will not be carrying a Down syndrome child. However, with the miscarriage risk of these tests, it has been estimated that for every 660 Down syndrome children that are detected and terminated in England and Wales each year, 400 children without Down syndrome die as well.[100] While there was reaction against the suggestion that these figures demonstrated a need to withdraw screening completely, it was admitted that “There is clearly an urgent need for wider medical and public debate about screening”.[101]

CVS and amniocentesis results require a complete analysis of the chromosomes (karyotype), which usually takes 1-3 weeks. FISH[102] has hastened the result return time to 48-72 hours. Uncultured amniotic fluid can also be used to determine levels of a protein (AFP) that is present in open neural tube defects.

3. Cordocentesis/fetal blood sampling

If the results of the amniocentesis are unclear or a quick result is needed, cordocentesis may be recommended. It can be used to diagnose infection as well as some genetic conditions. A needle is passed into the umbilical cord using ultrasound for guidance. There is a miscarriage risk of around 2%, or even higher if there are other problems with the pregnancy. This test is not done very often.[103]

Ethical issues

When you realize that many of these screening tests need to be done early in a ‘normal’ pregnancy, you can understand why it is that general practitioners often order them before the mother has had her first visit with an obstetrician. However, this means the doctor ordering the test may not have specialist knowledge of the conditions being tested for, and may not be able to explain fully what is involved.[104] Research shows that not all women are fully informed before testing[105] and there is sometimes a lack of dialogue about sensitive topics such as disability and termination.[106] This problem needs to be addressed. It is possible there will be time pressure, and it may be difficult to provide comprehensive genetic counselling in a busy general practice;[107] these are difficult issues to raise with someone who has just found out they are pregnant. Hence the continued ignorance of what these tests are for.

However, this is a violation of the informed consent process, which demands we know what and why procedures are being carried out on our bodies, before we agree to participate.

Comprehensive counselling allows parents to know what a test is for and what risks may be involved, which will help them decide whether they want to go ahead with it. Counselling will also help them mentally prepare in case the test result is bad. If an abnormality is detected, an experienced counsellor can tell them whether it is a condition that can be corrected during, or soon after, the pregnancy. If they decide to continue the pregnancy with an untreatable disorder, they can obtain information about their baby’s condition that will help them to plan for raising a child with a disability or illness. Counselling also enables the doctor to know whether closer monitoring of the pregnancy is required.

It occurs to me that one problem with increasing public awareness of available screening may be the effect it has on bonding between parents and child. If the parents know they can screen for abnormalities and abort the imperfect baby, will they consciously, or unconsciously, hold back affection until they know whether they will carry the pregnancy to term? Abortion would potentially be easier if they felt less attached to their baby. I think this would be an unhelpful result and may further reduce the ability of parents to love their children unconditionally as our Father in heaven loves us. We should be careful not to allow the easy availability of abortion to reduce our sense of responsibility for our offspring.

Prenatal screening for the purpose of detecting abnormalities in the baby, with a view to abortion, is not ethical for those who want to protect all human life. While extra tests may be done at times to see if a pregnancy needs to be monitored more closely—some parents would like to screen ‘just so they know’—the only definitive tests are CVS and amniocentesis (and cordocentesis), which carry a risk of miscarriage. It has been argued that it is difficult to justify these investigations (and the risk to the child) merely to satisfy your curiosity. However, there is an argument for the tests in that they may also enable doctors to plan closer monitoring of the ‘at risk’ babies, whether it be Down syndrome or not. In the case of chromosomal abnormalities that are incompatible with life, palliative care plans can then be put in place.

Nonetheless, undertaking these tests can make things harder. British neonatologist John Wyatt has noted that, in his experience, the knowledge gained from fetal screening when the baby is impaired does not so much help parents to prepare psychologically, as lead them to wait for the birth with increasing anxiety and distress. He is concerned that this damages the normal relationship between parents and child; instead of spending the pregnancy learning to love the developing baby unconditionally, parents are wondering how the child will measure up.[108]

Biblical teaching is clear on this subject: killing innocent human beings is wrong (Exod 20:13).[109]

In Australia in 2002-2003, 63.6% of fetuses diagnosed with Down syndrome, and about 76% of fetuses affected with neural tube defects, were either aborted or died in the womb.[110] Screening is now more widespread and so the relative number of babies aborted will have increased since then. It is now standard for all pregnancies to be screened for Down syndrome in many industrialized countries, with the unspoken expectation that abnormal babies will be aborted. Recent research on screening for Down syndrome is working on new ways to screen during fetal life that are cheaper and more efficient. Over 350 articles have been written on this subject in the medical literature in just the last five years.[111]

Down syndrome

Down syndrome, or trisomy 21, is one of the most common chromosomal abnormalities in live born children. It is caused by a failure of the chromosomes to separate properly during production of the mother’s eggs (usually) or during cell division early in development, resulting in three copies of chromosome 21 in all, or some, of the baby’s cells.[112] The parents do not pass it on—they would usually have normal chromosomes. Children with Down syndrome have varied abilities dependent on heredity and early upbringing. The extra genetic material in the additional chromosome 21 causes them to have a number of common physical characteristics that give them their distinctive appearance. A child with Down syndrome is generally delayed in reaching developmental milestones (such as sitting, crawling, walking, talking, toileting, etc.) but, as the Down Syndrome Society of South Australia reports on its website, “For most children with Down syndrome the future is brighter today than it might have been only a short while ago. Educational and medical techniques have made, and continue to make, great advances in helping children with Down syndrome lead a life of dignity, meaning and independence.”[113] The Stanford University School of Medicine Down Syndrome Research Center is among several units that have been exploring the condition and they have had promising results in animal trials using medication to improve memory.[114] In 2002-2003, Down syndrome affected 11.1 in every 10,000 live births, but after early detection and terminations of pregnancy were included, the estimated actual rate for trisomy 21 was 26.3 per 10,000 pregnancies.

A 2011 study from the Children’s Hospital in Boston interviewed over 2000 parents of Down syndrome children and found that “The overwhelming majority of parents surveyed report that they are happy with their decision to have their child with DS and indicate that their sons and daughters are great sources of love and pride”.[115] Interestingly, 79% of parents felt their outlook on life was more positive because of their child, only 5% felt embarrassed by them and only 4% regretted having them. Similarly, nearly all siblings regarded their relationship with a brother or sister with Down syndrome as positive and enhancing. Of older siblings, 88% felt that the experience had made them better people.[116]

Neuroscientist Dr Alberto Costa is conducting the first human trial on ways to improve memory in Down syndrome, but he has noticed a reduction in available research funding since a blood test to screen for Down syndrome in pregnancy has been in development. In 2011, research into Down syndrome—a condition affecting 300,000 to 400,000 people in the United States—received US$22 million, while cystic fibrosis research—affecting about 30,000 (one tenth the number of people who have Down syndrome)—received US$68 million. “The geneticists expect Down syndrome to disappear,” Costa says, “so why fund treatments?”[117]

Soon it is expected that all pregnancies will be screened for cystic fibrosis (CF), a hereditary condition that leads to thickened secretions by the glands of the body. It is one of the most common life-shortening genetic diseases in the Western world. Although it cannot be cured, with today’s improved treatment most people with CF are able to lead reasonably normal and productive lives. Currently, babies are screened for CF at birth in many countries, including Australia. This is morally good, as it allows all children with CF to receive treatment early. However, screening early in the pregnancy is intended to prevent these children being born.

Kits are now available which allow parents to test to see if they are carriers of the CF gene. Parents who find that they are both carriers—and thus at risk of having a CF-affected child—are offered genetic screening in pregnancy.

Cystic fibrosis (CF)

CF is a chronic disease due to a defective gene that causes the body to produce unusually thick, sticky mucus. The mucus clogs the lungs, which leads to life-threatening lung infections, and obstructs the pancreas by stopping natural enzymes from helping the body break down and absorb food.

The CF gene is inherited as an autosomal recessive mutation, meaning that if two carriers have a child, there is a 1 in 4 chance that it will be affected by CF. While in the 1960s children with CF survived on average for less than one year, improvement in treatment has greatly improved the outlook for them. Most children with CF are fairly healthy until they reach adulthood. They are able to participate in most activities and should be able to attend school. Many young adults with CF are able to complete their education and find employment.[118] In the United States, the average life expectancy in 2009 for people with CF was in the mid-thirties,[119] and in Canada it was 48.1 in 2010.[120] Much research is being done aimed at seeking a cure.

Although CF affects only 1 in 2500 Caucasian babies born, 1 in 25 people of European descent are carriers with no symptoms of the disease. The customer information in the ‘carrier testing kit’ warns that while some people know they are at risk of being a carrier because of family history, over 85% of children born with CF do not have a known family history of the disease.[121]

There are two types of screening tests for CF because it can be caused by many different types of genetic mutation. The basic model (checking the F508del gene) will detect 79% of carriers, and by testing both parents, 90% of ‘at risk’ couples are detected. The deluxe test (checking the 32 most common CF mutations) detects about 90% of carriers.[122]


Eugenics is “the science of improving a population by controlled breeding so as to increase the occurrence of desirable heritable characteristics” (Oxford English Dictionary). Are we witnessing, in prenatal screening, a form of population ‘improvement’ that makes sure we stop any ‘faulty products’ from being born?

There have been court cases assessing ‘wrongful birth’ in many countries now; parents have regularly sued for the cost of caring for a disabled child. (Sometimes these suits are an attempt to pay for care costs in a society that underfunds support for the disabled.)

There was a new development in 2000 when a French court agreed that a child had a ‘right not to be born’. This was in the case of Nicholas Perruche, who had been born deaf, partly blind and brain-damaged from a rubella infection (his parents had already been compensated in 1997). His mother had asked her doctor to check if she had rubella at the time of her pregnancy because she wanted to abort rather than risk having a disabled child. Her doctor made a mistake.

Then, in 2001, a French court agreed again that a child had a ‘right not to be born’ when they awarded damages to a boy with Down syndrome. His mother would have aborted him if she’d known he had the condition, but her doctor also made a mistake. As a result, medical insurance premiums rose and French doctors protested until the French Parliament introduced legislation protecting them from being sued every time a prenatal screening test gave an unreliable result.

How do you test whether a life is worth living? I would have thought it was more a metaphysical question than a legal one, and I know some judges who agree with me. However, others seem to think it is better to be dead than disabled. Ethicist Julian Savulescu has suggested that:

…if a child is born with afflictions so severe and a life so miserable that he or she would be considered better off dead, then a claim could reasonably be made on the child’s behalf that he or she was harmed by being born. Nicholas Perruche may have such a life, but Down syndrome is not generally so severe as to make life not worth living.[123]

He notes that many people describe a happy and worthwhile life for those with Down syndrome. His test of whether a life is worth living is this: would life-prolonging medical treatment be administered if this child developed a life-threatening condition? I would say that this does not measure whether the life is worth living so much as whether he thinks the life is worth living.

In fact, Savulescu would contend that even if a parent can claim damages (because they would have aborted the child if they’d known), a child has no legitimate claim because they have benefited from the mistake—the benefit of having a life of one’s own. Against this, the parents can have great harm done to them if they have a child that they cannot “accommodate into their lives” (his words) whether disabled or not. Therefore, Savulescu sees these court cases as further justification for procreative autonomy—the right of the parents to decide whether or not and when to have children, and the right to be given information so they can decide about their pregnancy options: “Children have a profound impact on their parents’ lives. For this reason, people should retain control over their reproduction.”[124] Other supporters of prenatal screening agree.

Discoverer of the DNA molecule, James Watson, suggests: “Reproductive decisions should be made by women… If you could just say, ‘My baby’s not going to have asthma’, wouldn’t that be nice?”[125] One doctor told me I would be negligent if I were looking after a pregnant woman and did not let her know that these prenatal screening tests existed. “It doesn’t mean that everyone has to have them,” he said, “but they must be given enough information to allow them to decide for themselves.” I agree—informed consent is very important in medicine.

Susan, who had watched her brother die from muscular dystrophy at 13 years of age, said, Women who have decided to make the decision to terminate will make it on their own moral beliefs, and they’re not going to change. This sort of option will give them a choice not to terminate the pregnancy. She underwent CVS and all was well.

You can understand the fear that some parents will have for their children, having seen the suffering of a loved one. I am not trying to play down the seriousness of congenital disease and the challenge it represents for the parents. I am trying to look at this situation from the perspective of the child. The arguments above are considering the child’s right to life on the basis of what suits the parents, and I would like parents to know what they’re getting into if they decide to have these tests. I don’t expect everyone to agree with me, but my point is that the issue of informed consent for prenatal screening is still a big problem.

Ultrasound technology is improving all the time, and it is possible that this contributes to some of the false positive results. With each improvement, more structures are visible in the baby, and there have been cases where abortion has been recommended for ‘abnormalities’ that were subsequently found to be normal structures that had just never been seen before with inferior machines.

As a student, I was present at the post-mortem examination after a mistaken diagnosis of porencephaly (abnormal cavities in the brain) led to the decision to abort a baby. The ‘malformation’ on the 18-week ultrasound was found to represent receding cysts in the choroid plexus. The baby was completely normal. Subsequent review of the scans by five senior ultrasonographers at the time found that all agreed with the diagnosis of porencephaly. It was only when they were more familiar with the higher resolution scans that they realized their mistake. A lot of diagnoses by inexperienced operators are changed when they are reviewed at specialist centres.

Many health professionals are aware that the consent process is often unsatisfactory. In 2007, British ultrasound specialist Hylton Meire said, “Women are being referred for amniocentesis on the basis of a very flimsy test. And I think they need to understand just how inaccurate it can be.”[126] At the time, he calculated that in the United Kingdom as many as 3200 women a year would lose a normal child because of miscarriage following CVS or amniocentesis. Obstetrician Andrew McLennan commented, “It’s not a eugenics project or euthanasia. It’s simply about offering every woman the choice to have further testing if the scan is abnormal.”[127]

However, it’s not just a problem in the United Kingdom. In many places, prenatal screening tests are routine or require a proactive ‘opt-out’ notification (partly due to time constraints), thus increasing the use of the tests at the expense of informed choice.[128] An observer in the United States wrote, “Pregnant women rarely know what their blood is being tested for, or that the results may lead to painful dilemmas involving disability and abortion”. And yet, in response to a proposed toughening up of consent laws in California, he said, “If the new laws result in one woman shunning screening, or the avoidable birth of a severely disabled child, the state and its people will be the losers”.[129]

Inherent in all these supportive comments is the idea that some lives are not worth living. You could say that simply existing is in the created child’s best interests, as life is a basic good, but the argument we are hearing is that it is only good if you are normal, healthy and wanted by your parents.

I would like to make several points here. The argument for reproductive autonomy ignores the fact that the best way to avoid having children you don’t want is to avoid sexual intercourse in the first place (though I realize this idea is immediately rejected in our self-gratifying society). Supporters of reproductive autonomy are ignoring the fact that when pregnancy occurs, the child already exists; hence the convenience of the ‘personhood’ debate—because if it isn’t human, it doesn’t matter what you do with it. But I would argue that the question is not about whether you want a particular child; it is about whether you want to kill it. What conditions are considered adequate grounds for abortion after screening? Where is society heading?

Well, for a start, in many places completely healthy babies are aborted simply because they are not the preferred gender. One paediatrician wrote:

Formerly, imperfections warranting termination were those incompatible with life, but things have changed and I have observed terminations for a range of treatable conditions, for example, gastroschisis (85% expected survival), low meningocoele (probably walk unaided), dysplastic changes in one kidney (which might never have caused any trouble), and even cleft lip. There seems to be at best a commitment to perfection these days; at worst, an intolerance of interference with personal aspirations. Just how much disease parents will be able to accept in their baby is unknown, but I fear a new Eugenics based on the New Genetics.[130]

Some paediatric surgeons are concerned that expertise they have gained in treating congenital abnormalities may not be passed on to their trainees; because so many affected children are being aborted, surgeons do not always have an opportunity to demonstrate the techniques. Extrapolating from there, those children not aborted will receive poorer quality treatment as a result of diminished expertise, and poorer community support as the parents and children are ostracized for the child’s (avoidable) existence. For diseases such as spina bifida, complications of Down syndrome and congenital heart disease, there are many surgical solutions for problems that are now considered grounds for abortion.

Disability groups and feminist supporters fear that when physicians encourage the abortion of fetuses with diseases or disabilities, they are fostering intolerance of the less-than-perfect people who have already been born. How will this make us think of them? How will it make them think of themselves? Anecdotal evidence gives cause for concern: in one study of 73 parents-to-be undergoing prenatal screening, 30% said they thought screening might encourage negative attitudes toward the disabled; and 50% thought that mothers of disabled children would be blamed for their failure to undergo screening or have abortions.[131] Disability groups are also concerned that fewer resources will be allocated for research and the treatment of congenital abnormalities, if these abnormalities become a feature of a less educated, less socioeconomically mobile class who are less able to access antenatal services that include prenatal screening.

American educator Charlotte Spinkston is concerned that when a disability is discovered through prenatal screening, termination of the pregnancy is often the only option offered as a first response. In her experience, far too many women are told of other options only after they have told health professionals of their decision not to abort. She says:

It is important that a range of available options be offered to families who receive diagnoses of disability in utero before they decide (when it is feasible to do so). It is crucial for families to be informed of community-based family information and support services as well as hospital-based services as soon as possible.[132]

So how do we know which lives are worth living and which ones are not? There are many disabled people who wish someone would ask them. Disability advocate Harriet Johnson writes:

The social-science literature suggests that the public in general, and physicians in particular, tend to underestimate the quality of life of disabled people, compared with our own assessments of our lives. The case for assisted suicide [read abortion] rests on stereotypes that our lives are inherently so bad that it is entirely rational if we want to die.[133]

She insists that the presence or absence of a disability doesn’t predict quality of life, and she is concerned that children with disabilities are being killed because parents prefer normal babies: “I have trouble with basing life-and-death decisions on market considerations when the market is structured by prejudice”.[134]

One study found that because most women have a lot of confidence in their doctors and rely on their advice, what may seem to be consumer demand is actually just medical dominance of antenatal care.[135] Unfortunately, the medicalization of pregnancy is a topic beyond the scope of this book.

I will leave it to you to decide whether you think there is a eugenics agenda here.

The experience of Dutch doctors practicing euthanasia on disabled newborns was published in 2005. These doctors developed the Groningen protocol, which aims to set the standard for doctors wishing to relieve “unbearable suffering” in severely impaired newborns.[136]

Disability in the Western world

Society has often singled out the disabled. In antiquity, children identified as weak or disabled were commonly abandoned and not considered worth rearing, with Aristotle approving it as an excuse for infanticide (no ultrasounds back then, therefore no chance to abort). The Judaeo-Christian culture, as recorded in the Bible, was more inclusive at times, with biblical records of the disabled living with their families: Mephibosheth, son of Jonathan, was crippled in both feet. King David showed kindness to him for Jonathan’s sake and he always ate at the king’s table (2 Samuel 9). However, the disabled were portrayed as helpless (2 Sam 5:6-8) and the deformed were excluded from the priesthood (Lev 21:17-23).[137]

According to Jayne Clapton and Jennifer Fitzgerald, the history of disability in the West has been characterized by the progressive development of several models of disability: the religious model, the medical/genetic model, and the rights-based model. These models influence how we respond to the disabled. Yet even though the models have changed over time, one thing about them remains constant—the idea of ‘otherness’.[138]

In the agrarian societies of pre-industrialization, when people lived by the seasons and the pace was less pressured, people perceived to have limitations often lived with their families. They were given tasks within their capabilities, but which helped the family as a whole to function. They were accommodated within the patterns of daily life. Others, though, could not stay with their families. Some were ostracized and their survival was threatened, because of a popular conception that such people were monsters and therefore unworthy of human status. Some became homeless and dislocated for other reasons such as poverty or shame. Mental illness was not understood and was often ascribed to evil forces. Religious communities responded to these groups of people in various ways, including seeking cures through exorcisms, purging, rituals and so on, or providing care, hospitality and service as acts of mercy and Christian duty to ‘needy strangers’.

Our Western society is not comfortable with disability.

Joseph Carey Merrick (1862-1890), also known as John Merrick, was an English man who was lame and had severe deformities, making his speech difficult to understand. Unable to find employment, he arranged to be exhibited as a human curiosity named the Elephant Man. He was visited by a surgeon named Frederick Treves, who invited Merrick to be examined and photographed. He was found to be sensitive and of normal intelligence and became well-known in London society after he went to live at the London Hospital. The official cause of his death was asphyxia, although Treves, who dissected the body, said that Merrick had died of a dislocated neck. He believed that Merrick—who had to sleep sitting up because of the weight of his head—had been attempting to sleep lying down, to ‘be like other people’.

His body is still preserved in the Royal London Hospital Museum. In 2001, it was proposed that Merrick had suffered from a combination of neurofibromatosis type I and Proteus syndrome. DNA tests conducted on his hair and bones have proved inconclusive.

In the post-industrial era, disability in Western society has been regarded as an individual affliction described in medical terms. The person is disabled—he has the problem, not society, and he has to deal with it. However, in a youth-obsessed, death-denying culture, disability is seen as a failure and those who suffer from disability are looked down upon. They are ‘impaired’. Society does not adequately support their needs, and so they become ‘handicapped’—not from the disability so much as the society that is unwilling to fully accommodate them.

While the campaign for ‘the rights of the disabled’ has brought some additional entitlements to people with disability, it has not significantly altered the way in which disability is viewed and so, despite changes in the law and some improvement in facilities for the disabled, some people’s lives have not necessarily changed for the better. In fact, new developments in genetic technology and reproductive technology threaten to further separate the person with the disability. With our increasing understanding of genetics, we seem to be expanding the population of the disabled to include people who have abnormal chromosomes, even if no abnormality has been physically expressed. They too are suffering discrimination, and even elimination, due to their impaired genes. Ironically, by demanding their ‘rights’, the disabled may be accentuating their ‘otherness’, thus affirming the assumption that they are a separate group.

Some people have suggested that it is not fair to expect society to pay the medical costs of disabled children when they could have been aborted. Colleagues of mine have come across cases of families who have been refused health insurance for their newborn child because their child’s disability was a ‘previously known condition’: the suggestion is that parents who do not screen their children and abort the defective samples are the negligent ones. What was initially presented as a parent’s choice in the name of freedom (i.e. prenatal screening) is becoming an obligation.

Will society become less tolerant of the disabled if fewer of them are born? Would it be better for a child to have no life at all? This is what one contributor to the Human Genome Project, Grant Sutherland, has suggested:

Anyone who’s born (with a disability) that we have to deal with, we have to deal with with compassion, with understanding. But if we can prevent the birth of handicapped individuals, then I think that society will be better off.[139]

The disability lobby condemned his remarks. Of course, society would be better off if no-one was ever afflicted with disease. But that will not be possible in this world. Anyone who dreams of a world without disability is doing just that: dreaming.

Perhaps we would all be better off if we regarded disability as part of a spectrum on which we all are placed—a dynamic spectrum that we could all move along, in different directions, as life and health have an impact on our lives. If we live in a fallen world, we have to expect some difficulties. According to the United Nations, around 10% of the world’s population (or 650 million) is living with disability—the world’s largest minority.[140] More people will become disabled after birth than before birth.[141] On average, in countries with life spans exceeding 70 years, 8 years (or 11.5%) of a person’s life will be affected by disability. Numbers will increase as the population ages.[142] This, too, is acknowledged in the Bible, with the frailty of old age portrayed for heroes such as Israel (Jacob), who lost his eyesight (Gen 48:10), and David, who could not keep himself warm (1 Kgs 1:1).

I work in the area of palliative care, which involves care of those with life-threatening illness. My patients often tell me that they don’t want to be a burden, but we will all be a burden at some time in our lives, from the first nappy change onwards. We are our brother’s keeper. It is normal to be disabled or dependent at times; this is part of what it means to live in a fallen world. It is only in the new creation that our bodies will be imperishable (1 Cor 15:42-44).

This idea informs the work of the WHO. The International Classification of Functioning, Disability and Health (ICF) is a classification of health and health-related domains that casts new light on the notions of ‘health’ and ‘disability’. It acknowledges that every human being can experience a decrease in health and thereby experience some degree of disability. Disability is not something that only happens to a minority of human beings. The ICF thus ‘mainstreams’ the experience of disability and recognizes it as a universal human experience. By shifting the focus from what caused the disease to how it affects the way we live, it places all health conditions on an equal footing, allowing them to be compared using a common measure for both health and disability.[143]

This, then, is what it means to be human.

  1. C Ronsmans and WJ Graham, ‘Maternal mortality: who, when, where, and why’, Lancet, vol. 368, no. 9542, 30 September 2006, pp. 1189-1200. 
  2. MC Hogan, KJ Foreman, M Naghavi, SY Ahn, M Wang, SM Makela, AD Lopez, R Lozano and CJL Murray, ‘Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5’, Lancet, vol. 375, no. 9726, 8 May 2010, pp. 1609-23. 
  3. ibid. 
  4. In Australia, leading direct causes of maternal death were amniotic fluid embolism, thromboembolism and hypertension. Leading indirect causes of maternal death were cardiac disease, psychiatric-related causes and non-obstetric haemorrhage. See EA Sullivan, B Hall and JF King, Maternal Deaths in Australia 2003-2005, Maternal deaths series no. 3, cat. no. PER 42, AIHW, Canberra, 2008. 
  5. S Abeywardana and EA Sullivan, Congenital Anomalies in Australia 2002-2003, Birth anomalies series no. 3, cat. no. PER 41, AIHW, Canberra, 2008. 
  6. ibid., p. vi. 
  7. ibid. 
  8. F Al-Yaman, M Bryant and H Sargeant, Australia’s Children: Their Health and Wellbeing 2002, AIHW cat. no. PHE 36, AIHW, Canberra, 2002, p. 103. 
  9. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Pre-pregnancy Counselling and Routine Antenatal Assessment in the Absence of Pregnancy Complications (C-Obs-3), College statement, RANZCOG, Melbourne, November 2009 (viewed 19 December 2011): 
  10. DL Heymann (ed.), ‘Rubella (German Measles), Congenital Rubella (Congenital Rubella Syndrome)’, in Control of Communicable Diseases Manual, 19th edn, American Public Health Association, Washington DC, 2008, pp. 529-34; S Reef, S Redd, E Abernathy and J Icenogle, ‘Rubella’, in Centers for Disease Control and Prevention (CDC), Manual for the Surveillance of Vaccine-Preventable Disease, 4th edn, CDC, Atlanta, 2008, chapter 14; CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th edn, eds W Atkinson, S Wolfe and J Hamborsky, Public Health Foundation, Washington DC, 2011, pp. 275-89. 
  11. S Reef and S Redd, ‘Congenital Rubella Syndrome’, in CDC, Manual for the Surveillance of Vaccine-Preventable Disease, op. cit., chapter 15. 
  12. Heymann (ed.), loc. cit. 
  13. SA Plotkin and S Reef, ‘Rubella vaccine’, in SA Plotkin, WA Orenstein and PA Offit (eds), Vaccines, 5th edn, Saunders, Philadelphia, 2008, pp. 735-72. 
  14. LE Riley, ‘Measles, mumps, varicella and parvovirus’, in DK James, PJ Steer, CP Weiner and B Gonik (eds), High Risk Pregnancy, 3rd edn, Saunders, Philadelphia, 2006, pp. 636-8. 
  15. Plotkin and Reef, loc. cit. 
  16. Australian Government Department of Health and Ageing (AGDHA), ‘Rubella’, in The Australian Immunisation Handbook, section 3.19, 9th edn, Office of Health Protection, Canberra, 2008. 
  17. CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, op. cit., pp. 301-24; M Marin, D Güris, SS Chaves, S Schmid, JF Seward and CDC, ‘Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR Recommendations and Reports, vol. 56, no. RR-4, 22 June 2007, pp. 1-40. 
  18. AGDHA, ‘Varicella’, in The Australian Immunisation Handbook, section 3.24, op. cit. 
  19. GN Papanicolaou and HF Traut, ‘The diagnostic value of vaginal smears in carcinoma of the uterus’, American Journal of Obstetrics and Gynecology, vol. 42, no. 2, August 1941, pp. 193-206. 
  20. AGDHA, National Cervical Screening Program, AGDHA, Canberra, 2009 (viewed 19 December 2011):; National Health and Medical Research Council (NHMRC), Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen Detected Abnormalities, NHMRC, Canberra, 2005. 
  21. LE Riley, Rubella in Pregnancy, UpToDate, Waltham MA, 7 June 2010 (viewed 19 December 2011): (subscription based) 
  22. A false negative test result indicates no abnormality when there really is one; a false positive result indicates an abnormality when there really isn’t one. 
  23. JMG Wilson and G Jungner, ‘Principles and Practice of screening for disease’, WHO Chronicle, vol. 22, no. 11, 1968, p. 473. 
  24. Also known as full blood examination (FBE), complete blood count (CBC), blood cell profile, blood count, haemogram. 
  25. J Strong, ‘Anaemia and white blood cell disorders’, in James et al. (eds), op. cit., pp. 867-9; IR Mabry-Hernandez, ‘Screening for iron deficiency anemia—including iron supplementation for children and pregnant women’, American Family Physician, vol. 79, no. 10, 15 May 2009, pp. 897-8. 
  26. RANZCOG, loc. cit. 
  27. Rhesus status is part of your blood type. 
  28. L Dean, Blood Groups and Red Cell Antigens, National Center for Biotechnology Information, Bethesda, 2005, chapter 4. 
  29. ibid. 
  30. World Health Organization (WHO), Sexually Transmitted Infections, fact sheet no. 110, WHO, Geneva, August 2011 (viewed 19 December 2011):; Western Australian Department of Health, Guidelines for Managing Sexually Transmitted Infections, section 2.7.9, WA Health, Shenton Park, 2010 (viewed 19 December 2011): 
  31. A Daley and L Gilbert, ‘Treponema pallidum (Syphilis)’, in P Palasanthiran, M Starr and C Jones (eds), Management of Perinatal Infections, Australasian Society for Infectious Disease (ASID), Sydney, 2002, pp. 42-4. 
  32. EK Johnson and JS Wolf Jr, Urinary Tract Infections in Pregnancy, WebMD, New York, 2011 (viewed 19 December 2011): 
  33. RL Sweet and RS Gibbs, Infectious Diseases of the Female Genital Tract, 5th edn, Lippincott Williams and Wilkins, Philadelphia, 2009, p. 256. 
  34. TM Hooton, Urinary Tract Infections and Asymptomatic Bacteriuria in Pregnancy, UpToDate, Waltham MA, 21 May 2012 (viewed 25 June 2012): (subscription based) 
  35. WHO, Mother-to-Child Transmission of HIV, WHO, Geneva, 2011 (viewed 19 December 2011): 
  36. DH Watts, ‘Human immunodeficiency virus’, in James et al. (eds), op. cit., pp. 620-21. 
  37. Joint Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis and Intergovernmental Commmittee on AIDS, Hepatitis and Related Diseases HIV Testing Policy Steering Group, National HIV Testing Policy 2006, F Bowden and K Stewart (chairs), AGDHA, Canberra, 2006; ML Giles, A Pedrana, C Jones, S Garland, M Hellard and SR Lewin, ‘Antenatal screening practice for infectious diseases by general practitioners in Australia’, Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 49, no. 1, February 2009, pp. 39-44. 
  38. BM Branson, HH Handsfield, MA Lampe, RS Janssen, AW Taylor, SB Lyss, JE Clark and CDC, ‘Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings’, MMWR Recommendations and Reports, vol. 55, no. RR-14, 22 September 2006, pp. 1-17. 
  39. Heymann (ed.), ‘Hepatitis viral’, in Control of Communicable Diseases Manual, op. cit., pp. 295-7. 
  40. A Mellor, ‘Routine antenatal screening’, Obstetrics and Gynaecology Magazine, vol. 11, no. 2, Winter 2009, pp. 13-15. 
  41. A Safir, A Levy, E Sikuler and E Sheiner, ‘Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome’, Liver International, vol. 30, no. 5, May 2010, pp. 765-70. 
  42. AGDHA, ‘Hepatitis B’, in The Australian Immunisation Handbook, section 3.6, op. cit.; CR MacIntyre, ‘Hepatitis B vaccine: risks and benefits of universal neonatal vaccination’, Journal of Paediatrics and Child Health, vol. 37, no. 3, June 2001, pp. 215-17. 
  43. Heymann (ed.), ‘Hepatitis viral’, op. cit. 
  44. Hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis and Blood Borne Virus and Sexually Transmissible Infections Subcommittee of the Australian Population Health Development Committee, National Hepatitis C Testing Policy, AGDHA, Canberra, May 2007. 
  45. RANZCOG, loc. cit.; Giles et al., loc. cit.; Hepatitis C Subcommittee and Blood Borne Virus and STIs Subcommittee, loc. cit. 
  46. SJ Buckley, ‘Ultrasound: not so safe and sound’, Nexus, vol. 9, no. 6, October-November 2002. 
  47. RANZCOG, loc. cit. 
  48. American College of Obstetricians and Gynecologists (ACOG), Routine Ultrasound in Low-Risk Pregnancy, practice pattern no. 5, ACOG, Washington DC, August 1997. 
  49. M Whitworth, L Bricker, JP Neilson and T Dowswell, ‘Ultrasound for fetal assessment in early pregnancy’, Cochrane Database of Systematic Reviews 2010, no. 4, 14 April 2010. 
  50. NW Cheung, JN Oats and HD McIntyre, ‘Australian carbohydrate intolerance study in pregnant women: implications for the management of gestational diabetes’, Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 45, no. 6, December 2005, pp. 484-5. 
  51. RANZCOG, Diagnosis of Gestational Diabetes Mellitus (C-Obs 7), College statement, RANZCOG, Melbourne, November 2011 (viewed 19 December 2011):–diagnosis-of-gestational-diabetes-mellitus-c-obs-7.html 
  52. CA Crowther, JE Hiller, JR Moss, AJ McPhee, WS Jeffries and JS Robinson, ‘Effect of treatment of gestational diabetes mellitus on pregnancy outcomes’, New England Journal of Medicine, vol. 352, no. 24, 16 June 2005, pp. 2477-86. 
  53. Heymann (ed.), ‘Group B Streptococcal Sepsis of the Newborn’, in Control of Communicable Diseases Manual, op. cit., pp. 585-7. 
  54. RANZCOG, Screening and Treatment for Group B Streptococcus in Pregnancy (C-Obs 19), College statement, RANZCOG, Melbourne, July 2011 (viewed 19 December 2011):–screening-and-treatment-for-group-b-streptococcus-in-pregnancy-c-obs-19.html 
  55. A Ohlsson and VS Shah, ‘Intrapartum antibiotics for known maternal Group B streptococcal colonization’, Cochrane Database of Systematic Reviews 2009, no. 3, 8 July 2009; SM Garland and M Starr, ‘Streptococcus, group B’, in Palasanthiran et al. (eds), op. cit., pp. 36-8. 
  56. J Garcia, L Bricker, J Henderson, M Martin, M Mugford, J Nielson and T Roberts, ‘Women’s views of pregnancy ultrasound: A systematic review’, Birth, vol. 29, no. 4, December 2002, p. 225-50. 
  57. As mentioned earlier, a false negative test result indicates no abnormality when there really is one; a false positive result indicates an abnormality when there really isn’t one. 
  58. C Gaff, J Newstead and M Saleh, ‘Testing and Pregnancy’, in Genetics Education in Medicine Consortium, Genetics in Family Medicine, Biotechnology Australia, Canberra, 2007. 
  59. WHO, Sickle-cell Disease and Other Haemoglobin Disorders, fact sheet no. 308, WHO, Geneva, January 2011 (viewed 19 December 2011):;E Dormandy, M Gulliford, S Bryan, TE Roberts, M Calnan, K Atkin, J Karnon, J Logan, F Kavalier, HJ Harris, TA Johnston, EN Anionwu, V Tsianakas, P Jones and TM Marteauik, ‘Effectiveness of earlier antenatal screening for sickle cell disease and thalassaemia in primary care: cluster randomised trial’, British Medical Journal, vol. 341, no. 7779, 30 October 2010, c5132; V Tsianakas, M Calnan, K Atkin, E Dormandy and TM Marteau, ‘Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs’ experiences’, British Journal of General Practice, vol. 60, no. 580, November 2010, pp. 822-8. 
  60. SA Devaney, GE Palomaki, JA Scott and DW Bianchi, ‘Noninvasive fetal sex determination using cell-free fetal DNA: A systematic review and meta-analysis’, Journal of the American Medical Association, vol. 306, no. 6, 10 August 2011, pp. 627-36. 
  61. D Tapon, ‘Prenatal testing for Down syndrome: comparison of screening practices in the UK and USA’, Journal of Genetic Counseling, vol. 19, no. 2, April 2010, pp. 112-30. 
  62. For an introduction to genetics, see the beginning of appendix III. 
  63. Pregnancies with the other autosomal trisomies do not survive. 
  64. M Bronshtein, S Rottem, N Yoffe and Z Blumenfeld, ‘First-trimester and early second-trimester diagnosis of nuchal cystic hygroma by transvaginal sonography: diverse prognosis of the septated from the nonseptated lesion’, American Journal of Obstetrics and Gynecology, vol. 161, no. 1, July 1989, pp. 78-82. 
  65. RJM Snijders, EA Thom, JM Zachary, LD Platt, N Greene, LG Jackson, RE Sabbagha, K Filkins, RK Silver, WA Hogge, NA Ginsberg, S Beverly, P Morgan, K Blum, P Chilis, LM Hill, J Hecker and RJ Wapner, ‘First-trimester trisomy screening: nuchal translucency measurement training and quality assurance to correct and unify technique’, Ultrasound in Obstetrics and Gynecology, vol. 19, no. 4, 1 April 2002, pp. 353-9. 
  66. DL Nisbet, AC Robertson, PJ Schluter, AC McLennan and JA Hyett, ‘Auditing ultrasound assessment of fetal nuchal translucency thickness: A review of Australian national data 2002-2008’, Australia and New Zealand Journal of Obstetrics and Gynaecology, vol. 50, no. 5, 2010, pp. 450-5. 
  67. NJ Wald, C Rodeck, AK Hackshaw and A Rudnicka, ‘SURUSS in perspective’, Seminars in Perinatology, vol. 29, no. 4, August 2005, pp. 225-35. 
  68. H Gottfredsdóttir, J Sandall and K Björnsdóttir, ‘“This is just what you do when you are pregnant”: a qualitative study of prospective parents in Iceland who accept nuchal translucency screening’, Midwifery, vol. 25, no. 6, December 2009, pp. 711-20. 
  69. Some more technical details: FTSS measures pregnancy associated placental protein-A (PAPP-A) and maternal serum free beta subunit human chorionic gonadotropin (free β-hCG). PAPP-A is a protein produced by both the embryo and placenta during pregnancy. Whereas elevated levels of this marker are not associated with adverse obstetric outcomes, low levels are associated with spontaneous fetal loss at less than 24 weeks gestation, low birth weight, preeclampsia, gestational hypertension, preterm birth and stillbirth, preterm premature rupture of membranes and placental abruption.Free β-hCG is a glycoprotein hormone produced during pregnancy by the developing embryo and later by the placenta. Low maternal serum levels of free β-hCG during the first trimester are associated with low birth weight and miscarriage.An increased serum level of free β-hCG with decreased PAPP-A indicates an increased risk of trisomy 21, whereas low levels of both analytes indicate increased risk of trisomy 18. The combination of maternal age with the first-trimester markers NT, PAPP-A and free β-hCG increases the detection rate of trisomy 21 to around 80%-90%. The combined first-trimester screen (scan plus bloods) has a diagnosis rate of 90% and a false positive rate of 5%. 
  70. KH Nicolaides, ‘Screening for fetal aneuploidies at 11 to 13 weeks’, Prenatal Diagnosis, vol. 31, no. 1, January 2011, pp. 7-15. 
  71. L Dugoff, JC Hobbins, FD Malone, TF Porter, D Luthy, CH Comstock, G Hankins, RL Berkowitz, I Merkatz, SD Craigo, IE Timor-Tritsch, SR Carr, HM Wolfe, J Vidaver and ME D’Alton, ‘First-trimester maternal serum PAPP-A and free-beta subunit human chorionic gonadotropin concentrations and nuchal translucency are associated with obstetric complications: A population-based screening study (The FASTER Trial)’, American Journal of Obstetrics and Gynecology, vol. 191, no. 4, 2004, pp. 1446-51. 
  72. K Barlow-Stewart and G Parasivam (eds), The Australasian Genetics Resource Book, 8th edn, The Centre for Genetics Education, St Leonards, 2007. 
  73. KO Kagan, I Staboulidou, J Cruz, D Wright and KH Nicolaides, ‘Two-stage first-trimester screening for trisomy 21 by ultrasound assessment and biochemical testing’, Ultrasound in Obstetrics and Gynecology, vol. 36, no. 5, November 2010, pp. 542-7; N Maiz and KH Nicolaides, ‘Ductus venosus in the first trimester: contribution to screening of chromosomal, cardiac defects and monochorionic twin complications’, Fetal Diagnosis and Therapy, vol. 28, no. 2, August 2010, pp. 65-71. 
  74. GE Palomaki, EM Kloza, GM Lambert-Messerlian, JE Haddow, LM Neveux, M Ehrich, D van den Boom, AT Bombard, C Deciu, WW Grody, SF Nelson and JA Canick, ‘DNA sequencing of maternal plasma to detect Down syndrome: An international clinical validation study’, Genetics in Medicine, vol. 13, no. 11, November 2011, pp. 913-20. 
  75. FM Ndumbe, O Navti, VN Chilaka and JC Konje, ‘Prenatal diagnosis in the first trimester of pregnancy’, Obstetrical and Gynecological Survey, vol. 63, no. 5, May 2008, pp. 317-28. 
  76. SJ Buckley, ‘Ultrasound Scans—Cause for Concern?’ Kindred, vol. 24, December 2007-February 2008, pp. 12-23. 
  77. E Sheiner, I Shoham-Vardi and JS Abramowicz, ‘What do clinical users know regarding safety of ultrasound during pregnancy?’, Journal of Ultrasound in Medicine, vol. 26, no. 3, March 2007, pp. 319-25. 
  78. JP Neilson, ‘Ultrasound for fetal assessment in early pregnancy’, Cochrane Database of Systematic Reviews 1998, no. 4, 26 October 1998 (reprinted in Cochrane Library, no. 4, 2007). 
  79. SE Simonsen, DW Branch and NC Rose, ‘The complexity of fetal imaging: reconciling clinical care with patient entertainment’, Obstetrics and Gynecology, vol. 112, no. 6, December 2008, pp. 1351-4. 
  80. ‘Surgery on baby in womb cures spina bifida’, Sydney Morning Herald, 23 November 1998. 
  81. NS Adzick, EA Thom, CY Spong, JW Brock III, PK Burrows, MP Johnson, LJ Howell, JA Farrell, ME Dabrowiak, LN Sutton, N Gupta, NB Tulipan, ME D’Alton and DL Farmer, ‘A randomized trial of prenatal versus postnatal repair of myelomeningocele’, New England Journal of Medicine, vol. 364, no. 11, 17 March 2011, pp. 993-1004. 
  82. Coping with the news that there is something wrong with your baby is discussed in chapter 9. 
  83. Some more technical details: second-trimester maternal serum screening involves measurement of alphafetoprotein (AFP), free beta or total human chorionic gonadotropin (free β-hCG or total hCG) and unconjugated estriol (uE3), together sometimes known as the ‘triple test’ or, if it includes inhibin A, the ‘quadruple (quad) test’.AFP is a normal fetal protein that can also be detected in maternal serum. Normally, serum concentrations rise until the third trimester and then fall to non-pregnant concentrations at delivery. The concentration of AFP in both the amniotic fluid and the mother’s serum also rises with a fetal neural tube defect in 80% of affected fetuses (spina bifida), with a false positive rate of 3%, in the second trimester (see R Harris, ‘Regular review: Maternal serum alphafetoprotein in pregnancy and the prevention of birth defect’, British Medical Journal, vol. 280, no. 6225, 17 May 1980, pp. 1199-1202).There are several other causes for such a rise, including other fetal malformations, multiple pregnancy, threatened abortion and intrauterine death, but the most common reason for an abnormal AFP level is an inaccurate estimated gestational age. Higher levels of maternal serum AFP appear to correlate with a higher incidence of poor pregnancy outcome, such as intrauterine growth restriction, haemorrhage, gestational hypertension, spontaneous preterm labour and delivery, and perinatal morbidity.Unlike in the first trimester, higher levels of free β-hCG or total hCG in the second trimester are correlated with a higher frequency of perinatal complications such as gestational hypertension, preterm labour or delivery, and stillbirth.Unconjugated estriol (uE3) is an oestrogen only made by the placenta, and low (sometimes undetectable) maternal serum levels are associated with fetal chromosomal abnormalities, structural anomalies (anencephaly), fetal death and a number of fetal metabolic disorders.Inhibin A is also a second-trimester marker made by the placenta. High serum levels are associated with triploidy (69 chromosomes in each cell) or the loss of one twin in the first trimester (see KM Goodwin, PJ Sweeney, GM Lambert-Messerlian and JA Canick, ‘High maternal serum inhibin A levels following the loss of one fetus in a twin pregnancy’, Prenatal Diagnosis, vol. 20, no. 12, December 2000, pp. 1015-7). 
  84. Barlow-Stewart and Parasivam, loc. cit. 
  85. See appendix III for more information about genetic test results. 
  86. P Wieacker and J Steinhard, ‘The prenatal diagnosis of genetic diseases’, Deutsches Ärzteblatt International, vol. 107, no. 48, 3 December 2010, pp. 857-62. 
  87. NJ Wald, A Kennard, JW Densem, HS Cuckle, T Chard and L Butler, ‘Antenatal maternal serum screening for Down’s syndrome: results of a demonstration project’, British Medical Journal, vol. 305, no. 6850, 15 August 1992, pp. 391-4. 
  88. MD Coory, T Roselli and HJ Carroll, ‘Antenatal care implications of population-based trends in Down syndrome birth rates by rurality and antenatal care provider, Queensland, 1990-2004’, Medical Journal of Australia, vol. 186, no. 5, 5 March 2007, pp. 230-4. 
  89. H Greely, ‘Get ready for the flood of fetal gene screening’, Nature, vol. 469, no. 7330, 20 January 2011, pp. 289-91, cited in K Hawkins, ‘Wrong to use prenatal genetic testing to push for abortion’,, 5 April 2011 (viewed 30 June 2012): 
  90. Gaff et al., loc. cit. 
  91. JC Sapp, SC Hull, S Duffer, S Zornetzer, E Sutton, TM Marteau and BB Biesecker, ‘Ambivalence toward undergoing invasive prenatal testing: an exploration of its origins’, Prenatal Diagnosis, vol. 30, no. 1, January 2010, pp. 77-82. 
  92. CA Hyland, GJ Gardener, H Davies, M Ahvenainen, RL Flower, D Irwin, JM Morris, CM Ward and JA Hyett, ‘Evaluation of non-invasive prenatal RHD genotyping of the fetus’, Medical Journal of Australia, vol. 191, no. 1, 6 July 2009, pp. 21-5. 
  93. Barlow-Stewart and Parasivam, loc. cit. 
  94. Subsequent management is discussed in chapter 9. For further explanation of genetics, see appendix III. 
  95. A Tabor and Z Alfirevic, ‘Update on procedure-related risks for prenatal diagnosis techniques’, Fetal Diagnosis and Therapy, vol. 27, no. 1, January 2010, pp. 1-7; Z Alfirevic, K Sundberg and S Brigham, ‘Amniocentesis and chorionic villus sampling for prenatal diagnosis’, Cochrane Database of Systematic Reviews 2003, no. 3, 21 July 2003 (reprinted in Cochrane Library, no. 4, 2007). 
  96. WA Grobman, M Auger, LP Shulman and S Elias, ‘The association between chorionic villus sampling and preeclampsia’, Prenatal Diagnosis, vol. 29, no. 8, August 2009, pp. 800-803; A Khalil, R Akolekar, P Pandya, A Syngelaki and K Nicolaides, ‘Chorionic villus sampling at 11 to 13 weeks of gestation and hypertensive disorders in pregnancy’, Obstetrics and Gynecology, vol. 116, no. 2, part 1, August 2010, pp. 374-80. 
  97. H Firth, ‘Chorion villus sampling and limb deficiency—cause or coincidence?’, Prenatal Diagnosis, vol. 17, no. 13, Deceber 1997, pp. 1313-30. 
  98. Alfirevic et al., ‘Amniocentesis and chorionic villus sampling’, loc. cit. 
  99. RD Orr, Medical Ethics and the Faith Factor, Eerdmans, Grand Rapids, 2009, p. 419. 
  100. F Buckley and SJ Buckley, ‘Wrongful deaths and rightful lives—screening for Down syndrome’, Down Syndrome Research and Practice, vol. 12, no. 2, October 2008, pp. 79-86. 
  101. P Summerfield, ‘Prenatal screening for Down’s syndrome: balanced debate needed’, Lancet, vol. 373, no. 9665, 28 February 2009, p. 722. 
  102. FISH (fluorescence in situ hybridization) is a technique used to detect specific features in DNA on chromosomes. 
  103. Tabor and Alfirevic, loc. cit. 
  104. HJ Harris, ‘The primary care perspective of quality in clinical genetics service—United Kingdom as an example’, in U Kristoffersson, J Schmidtke and JJ Cassiman (eds), Quality Issues In Clinical Genetic Services, Springer, London, 2010, pp. 75-82. 
  105. HJ Rowe, JRW Fisher and JA Quinlivan, ‘Are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using Multidimensional Measure of Informed Choice’, Australian and New Zealand Journal of Obstetricians and Gynaecologists, vol. 46, no. 5, October 2006, pp. 433-9. 
  106. JM Hodgson, LH Gillam, MA Sahhar and SA Metcalfe, ‘“Testing times, challenging choices”: An Australian study of prenatal genetic counseling’, Journal of Genetic Counseling, vol. 19, no. 1, February 2010, pp. 22-37. 
  107. C Nagle, S Lewis, B Meiser, J Gunn, J Halliday and R Bell, ‘Exploring general practitioners’ experience of informing women about prenatal screening tests for foetal abnormalities: A qualitative focus group study’, BMC Health Services Research, vol. 8, no. 114, 28 May 2008. 
  108. J Wyatt, Matters of Life and Death, 2nd edn, IVP, Leicester, 2009, p. 174. 
  109. The arguments for and against abortion are examined in chapter 7. A discussion about responding to disability is found in chapter 9. 
  110. Abeywardana and Sullivan, loc. cit. 
  111. M Hill, Trisomy 21, UNSW Embryology Wiki, Sydney, 29 May 2012 (viewed 2 July 2012): 
  112. 3%-4% of trisomy 21 is due to a ‘balanced’ translocation of chromosome 21 on to another chromosome (usually chromosome 14). When this occurs, the parent with the balanced translocation has the normal amount of genetic material, but it is distributed unevenly so that during production of the egg (or sperm), there is an uneven distribution resulting in trisomy at fertilization. 
  113. Down Syndrome Society of South Australia (DSSSA), About DS: General Overview, DSSSA, Greenacres, 2006 (viewed 20 December 2011): 
  114. S Heyn, ‘Pharmacotherapy improves cognitive performance in a Down syndrome mouse model’, News and Views, vol. 9, 2007 (viewed 20 December 2011): 
  115. BG Skotko, SP Levine and R Goldstein, ‘Having a son or daughter with Down syndrome: Perspectives from mothers and fathers’, American Journal of Medical Genetics Part A, vol. 155, no. 10, October 2011, pp. 2335-47. 
  116. ibid. 
  117. D Hurley, ‘A drug for Down syndrome’, New York Times Magazine, 29 July 2011. 
  118. PubMed Health, ‘Cystic fibrosis’, A.D.A.M. Medical Encyclopedia, PubMed Health, Bethesda, 1 May 2011 (viewed 20 December 2011): 
  119. Cystic Fibrosis Foundation, What is the Life Expectancy for People Who Have CF (in the United States)?, Cystic Fibrosis Foundation, Bethesda, 8 May 2011 (viewed 1 July 2011): 
  120. Canadian CF Patient Data Registry Working Group, Canadian Cystic Fibrosis Patient Data Registry Report 2010, Cystic Fibrosis Canada, Toronto, 2010, p. 3. 
  121. Genea, Before Getting Pregnant, Genea, Sydney, 2011 (viewed 2 July 2012): 
  122. ibid. 
  123. J Savulescu and M Spriggs, ‘Is there ever a “right not to be born”?’ Australian Medicine, vol. 14, no. 6, 1 April 2002, p. 8. 
  124. ibid. 
  125. JD Watson in ‘A Conversation with James D Watson’, interview with J Rennie, Scientific American, April 2003, p. 69. 
  126. L Hall, ‘Healthy babies “at risk”: UK doctor questions Down test’, Sun-Herald, 26 August 2007, p. 22. 
  127. ibid. 
  128. J Searle, ‘Fearing the worst—why do pregnant women feel “at risk”?’, Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 36, no. 3, August 1996, pp. 279-86. 
  129. P Billings, ‘Stem cell research: Dangerous territory?’ New Scientist, vol. 2576, November 2006. 
  130. J Whitehall, ‘The challenge of the new genetics’, Luke’s Journal, December 1996. 
  131. E Kristol, ‘Picture perfect: the politics of prenatal testing’, First Things, vol. 32, April 1993, pp. 17-24. 
  132. C Spinkston, ‘He giveth more grace’, Leadership Perspectives in Developmental Disability, vol. 3, no. 1. 
  133. HM Johnson, ‘Unspeakable conversations’, New York Times Magazine, 16 February 2003. 
  134. ibid. 
  135. Searle, loc. cit. 
  136. The protocol was introduced in two medical journals: see E Verhagen and PJJ Sauer, ‘The Groningen protocol: Euthanasia in severely ill newborns’, New England Journal of Medicine, vol. 352, no. 10, 10 March 2005, pp. 959-62; and AAE Verhagen and PJJ Sauer, ‘End-of-life decisions in newborns: An approach from the Netherlands’, Pediatrics, vol. 116, no. 3, September 2005, pp. 736-39. 
  137. Further discussion of the biblical understanding of disability is found in chapter 9. 
  138. J Clapton and J Fitzgerald, The History of Disability: A History of ‘Otherness’, Renaissance Universal, London, 2011 (viewed 20 December 2011): 
  139. S Dow, ‘Don’t play God with our lives, plead disabled’, Sun-Herald, 25 February 2001, p. 54. 
  140. United Nations Secretariat for the Convention on the Rights of Persons with Disabilities (SCRPD), Fact Sheet on Persons with Disabilities, SCRPD, New York, 2006 (viewed 20 December 2011): 
  141. Australian Bureau of Statistics (ABS), Disability, Ageing and Carers, Australia: Summary of Findings, ABS cat. no. 4430.0, ABS, Belconnen, 2003. 
  142. SCRPD, loc. cit. 
  143. WHO, Towards a Common Language for Functioning, Disability and Health ICF, WHO, Geneva, 2002, pp. 2-3 (viewed 20 December 2011):