Historical Public health, Legal and Ethical aspects of abortion

Transcription

1 Historical Public health, Legal and Ethical aspects of abortion Kristina Naidoo Consultant Gynaecologist Clinical Lead Abortion Care Service St Mary s Hospital Manchester

2 Introduction Evolution of the law Public Health and Epidemiology UK statistics Ethical and legal controversies

3 Types of law Case law (also known as common law) Legislation Primary- Acts of Parliament Secondary- Statutory instruments Professional law or codes of practice GMC/NMC Quasi-law- e.g. DoH guidance

4 The law: England, Scotland and Wales Anglo-Saxon Law Lord Ellenborough s Act 1803 Offences against the Person Act 1861

5 Offences Against the Person Act 1861: Attempts to procure abortion.whosoever, with to procure the miscarriage of any woman,, shall administer to her or cause to be taken by her any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, shall be guilty of felony The 1861 Act does not apply to Scotland.

6 The law: England, Scotland and Wales Infant Life (Preservation) Act 1929 Rex v Bourne (1939) Abortion Act 1967 Human Fertilisation and Embryology Act 1990

7 Abortion Act 1967 Statutory grounds for induced abortion The grounds for abortion are set out in Sections 1 (1) (a)-(d) of the Abortion Act. A The continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated: Abortion Act 1967 as amended, Section 1(1)(c). B The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman: Section 1(1)(b). C The pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman: Section 1(1)(a). D The pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman: Section 1(1)(a). E There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped: Section 1(1)(d). Abortion is legal in Great Britain if two registered doctors are of the opinion, formed in good faith (except in an emergency) that one of the stipulated grounds are met.

8 Abortion Act 1967 The Act also permits abortion to be performed in an emergency if one doctor is of the opinion formed in good faith that termination is immediately necessary. F to save the life of the pregnant woman: Section 1(4) G to prevent grave permanent injury to the physical or mental health of the pregnant woman: Section 1(4). It appears that item B above is the same as this item. Can you please clarify. (This clause covers emergencies where only one doctor needs to

9 Role of Nurses May lawfully carry out treatment in medical abortion Doctor prescribes and remains responsible RCN v DHSS 1982

10 The Law : Northern Ireland Offences against the Person Act 1861 Criminal Justice Act (NI) 1945 an equivalent to the Infant Life Preservation Act.with intent to destroy the life of a child capable of being born alive.shall be guilty of felony.unless for the purpose only of preserving the life of the mother.

11 Judicial reviews Guidelines issued 2009 Law unclear Northern Ireland Redrafted guidance 2010 and 2013 but not yet reissued

12 The Law : Northern Ireland In 2013 Sarah Ewert made public travelled to England for TOP of fetus with anencephaly In 2015 a high court judge ruled the failure to provide legal exceptions breached human rights obligations In February 2016 Stormont assembly members voted 59 to 40 against amending legislation to allow terminations in cases of fatal fetal abnormality and sexual crime

13 Northern Ireland Gynaecologists reluctant to perform abortions Approx. 50 a year In 2013, 802 women travelled to England for an abortion

14 Practicalities of the Law NHS premises are automatically approved as long as they are a hospital.. Independent sector, no automatic approval All premises must be individually approved. Overseen by the Care Quality Commission, the body for monitoring and regulating healthcare.

15 HSA forms HSA forms must be signed by two registered practitioners as outlined in the 1967 Act. The ground or grounds are selected. HSA2 is used infrequently in an emergency and only needs signing by one doctor. HSA4 is the notification to the Chief Medical Officer submitted within 14 days 5 pages long, detailed information relating to demographics, immediate complications, etc.

16 DH Guidance 2014 How doctors should conduct the certification for abortion. Acknowledges that many medical abortion services are now nurse-led. Although the 1967 Act does not require this, good practice that one of the doctors sees the pregnant woman. A doctor can rely on the information of the multidisciplinary team but should review the clinical records of the individual woman.

17 The doctors opinion in good faith Reasons for request Practical and emotional consequences of options Certainty of decision Absence of coercion

18 Public Health and Epidemiology

19 World Context 200 million pregnancies occur per year Around 1/5 end in induced abortion Of which half are unsafe (person performing the abortion lacking skills or environment lack minimum standards) Est. 47,000 maternal deaths worldwide related to abortion Est. 5 million women suffer disability due to complications Vast majority in developing countries.

20 Illegal abortion Prior to 1967 Act, illegal abortions were performed often by lay untrained individuals. Important public health benefits of safe and legal abortion. Vera Drake film directed by Mike Leigh set in the 1950s and highly recommended

21 1930 s Common forms of interference were: Syringe e.g. Higginson s with soapy water, Dettol or drugs causing embolus Female pills Caster oil Slippery elm bark Catheter Knitting needle/ crochet hook

22 1940 s 2665 cases published by Davis Estimated 90% illegal (often self induced) Mean hospital stay 13 days Fever in 84%, gross infection in 124 (5%) Five deaths 3 septicaemia 2 chemical burns

23 Deaths from abortion

24 CEMACE: Maternal mortality Abortion mortality 8,526,583 maternities 451 direct deaths Rate 5.3 per 100,000 2,295,872 7 deaths Rate 0.30 per 100,000

25 Mortality: US data Gestation (Bartlett et all, 2004) Mortality rate per 100,000 8 or less Relative risk

26 UK Statistics Prevalence By age % women will have experienced an abortion Most common gynae procedure in young women General increase since 1969 until 2007 after which it has gradually fallen In 2014 rate 15.9 per thousand. Lowest for 16 years. Greatest number in year age group Highest rate in women aged 22 (30 per 1,000) Under-16 abortion rate 2.5 per 1,000 Under per 1,000

27 Abortions in young people E&W 2014 Age No. of abortions < , & 17 9, ,238

28 Grounds (E&W 2014) Grounds for abortion No (%) A. Threat to life 57 (0.03) B. Permanent injury 136 (0.07) C. Physical/ mental health 180,680 (97.5) D. Risk to existing children 1,726 (0.9) E. Risk of serious handicap 2,732 (1.47)

29 Abortions by gestation (E&W 2014) Gradual reduction in gestation DH initiatives 92% of abortions were carried out at under 13 weeks gestation 80% were at under 10 weeks gestation cf 79% in 2013 and 60% in 2004

30 Method of abortion (E&W 2014) Medical abortion accounted for 51% 20% in 2004 First time medical has exceeded surgical Percentage having a repeat abortion 37% 50% have existing children

31 Funding and place of abortion Over the last decade particularly, the NHS has increasingly funded abortions Improved regional inequalities Compared to the late 1990s, fewer abortions are being performed in an NHS setting. Independent sector performs procedures in freestanding clinics, sometimes several miles from hospitals Not suitable settings for women with certain medical conditions e.g. morbid obesity. Need for critical mass of NHS experience and training, risk of deskilling.

32 Scotland Dugald Baird in Aberdeen initiated an enlightened approach to fertility regulation and research on medical abortion In % of abortions medical and 79% in 2013 (49% in E&W) 99% of abortions are performed within the NHS Less availability for later abortions Pathways in place for travel to England

33 How do women feel? Ethical and legal controversies Personhood- autonomous individual Women s issues Reproductive rights Public health issue of unsafe abortion Respect for dignity and self-determination Full and equal citizenship

34 Status of Fetus The fetus has no legal status until after birth, applies even after viability. Emotionally, more complex and the pregnant woman and healthcare professionals are affected by the increase in maturity of the fetus. This is reflected in the law as the grounds for abortion above 24 weeks are more limited.

35 Status of putative father The decision to terminate a pregnancy rests with the woman and her doctors. The woman s spouse/partner/putative father have no rights to demand or prevent abortion e.g. Paton v BPAS 1979 Upheld at European level 1981

36 Four views of abortion 1. Absolute prohibition 2. Only allowable in tragic situations 3. On health/psychological grounds 4. On demand

37 Position of health professionals Health professionals with a consciencious objection to abortion may to opt out of direct care to women requesting abortion except in an emergency (Abortion Act) These individuals should inform women of their views. Doctors/nurses who object to abortion should not impose their view on others but may explain their views if invited to do so

38 Position of health professionals Doctors and nurses cannot claim exemption from giving advice about access to abortion or performing the preparatory steps such as referral to the appropriate doctor. It is unethical for doctors/nurses to cause who object to cause unreasonable delay or to compromise the possibility of obtaining a legal abortion.

39 RCOG report 2010 Fetal awareness Lack of connection between thalamus and cerebral cortex before 24 weeks Scientific evidence such that it is generally thought that it is impossible for a fetus to be sentient that is experience sensation such as pain before 24 weeks of gestation There is debate that even after 24 weeks when the connections to the cerebral cortex have been laid down that the fetus is sentient then

40 Fetus with signs of life Must be registered as a live birth Therefore death needs to be confirmed Irrespective of gestation Must then be referred to the Coroner RCOG recommends feticide only after 21+6 days What are signs of life?

41 Under 16s Fear that their parents will disown them Women under age 16, who do not wish to involve their parent or guardian can consent to treatment if they fulfil the Fraser guidelines Issues to be considered Care of period of abortion Child protection

42 Fraser guidelines 1985 UPSSI

43 DoH Guidance for under 16s

44 Minors without capacity

45 Safeguarding

46 Recommended websites