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In February the Royal College of General Practitioners  (RCGP) announced their support for the decriminalisation of abortion. This decision was based on a poll, which only 8.2% of their 53,724 members responded to. 62% of those responding said they supported decriminalisation.

The RCGP now joins the British Medical Association, Royal College of Obstetricians and Gynaecologists, Royal College of Nurses, Faculty of Sexual and Reproductive Health and Royal College of Midwives who have proclaimed their support for decimalisation.

The RCGP states that supporting decriminalisation ‘is about providing non-judgemental care to our patients’ so ‘women who face the difficult decision to proceed with an abortion are not disadvantaged by the legal system.’

Abortion in the UK is illegal by way of sections 58 and  59 of the Offences Against the Person Act 1861 (OAPA). However, the Abortion Act 1967 allows for abortion in Great Britain (it does not extend to Northern Ireland) up to 24 weeks for certain criteria, as assessed by two medical doctors, the Abortion Act also has specific provisions for conscientious objection. Decriminalisation aims to remove sections 58 and 59 of the OAPA, this will mean that there is no requirement for the Abortion Act, including its conscientious objection clauses. Berer, a keen advocate for abortion, links criminalisation to the ‘glorification of the fetus’, in a ‘male dominated society’ that ultimately ‘aims to control women’. For Berer the argument is simple – improve access to abortion, reduce maternal deaths and physical harm. There is no place in her argument for any competing interest of the fetus or any other risks or morbidity associated with abortion. Yet even Berer recognises that except for Canada, ‘no other country, no matter how liberal its law reform, has been willing to take abortion completely out of the law that delimits it’.

The law therefore does serve a purpose: to deter and balance the needs of the baby with that of the woman as well as providing legal sanctions.

Much has been made about the punitive effects of the current law which pro abortionists say risks both women and doctors being prosecuted. Sally Sheldon, another strong pro abortion voice, concedes that: ‘Sections 58–60 of the OAPA are infrequently charged. Police statistics record fewer than ten prosecutions per year under ss 58 and 59 combined in England and Wales, the great majority of which would appear to have been brought in the context of assaults on a pregnant woman or the non-consensual administration of abortifacients. [There have been] just two convictions of women who have unlawfully procured miscarriages in the last ten years (each acting well after viability), and no convictions of clinicians…acting in a professional role.’

This suggests the law is both useful and not unfairly punitive.

If one wants to consider the deterrent effects of the OAPA then one only needs to consider Northern Ireland where the Abortion Act does not apply. Two things are striking about Northern Ireland:

  1. Despite its restrictive abortion laws there have been no headline grabbing cases of botched abortions or deaths. (Arguably, if we want to read about these we need to go to England and look to providers such as Marie Stopes who have been involved in both poor care as identified by CQC and maternal death.)
  2. The Northern Ireland group ‘Both lives matter’ assert that 100,000 lives have been saved who would have been otherwise aborted if they had Great Britain’s abortion laws. This assertion was upheld as valid by the advertising standards authority.

There are other things the profession needs to consider before calling for the removal of the deterrent effects of the law.

The profession needs to be mindful that the link between abortion and mental health has not been clarified and certainly one cannot say that access to abortion reduces the chance of mental health problems from an unwanted pregnancy. Abortion pills used for early abortion are not risk free: the FDA reported that mifepristone was associated with 22 deaths in the US in 2017. In addition there is little to suggest that the liberal abortion provisions in Great Britain have done anything to stop women risking their lives acquiring abortion pills illegally on line, so it is hard to argue that decriminalisation will improve these numbers.

The strongest push for decriminalisation comes from the abortion industry itself. British Pregnancy Advisory Service is the largest providers of abortion services in England and Wales (the financial interest of abortion services in wanting to see a change in the law should not be disregarded). Their 2017 -2018 report  (on page 9 ) states their ‘We Trust Women’ campaign resulted in the Reproductive Health (Access to Terminations) Bill 2017 -2018, and the ‘We Trust Women’ campaign continues to strongly advocate for decriminalisation both in Great Britain and N Ireland. Not surprisingly, BPAS have welcomed the RCGP move.

It seems that the RCGP has jumped on the bandwagon of abortion decriminalisation. Yet it is unclear why the law needs scrapping.

Dr Rosemarie Anthony-Pillai

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Stories abound on social media. Documentaries and podcasts open the lid on the growing phenomenon of gender dysphoric children presenting in greater and greater numbers. In our field many of us hear first-hand the heart-breaking stories of children struggling with their gender identity and share a deep concern for their welfare.

Last year around 2,000 transgender or gender questioning children (a 300 percent increase in three years) were seen by the Tavistock and Portman NHS Trust’s Gender Identity Development Service (GIDS) with around 15% of them approved for puberty blockers (Gonadotropin-Releasing Hormone agonists, GnRHa).

In 2008 the Endocrine Society approved puberty blockers for transgender adolescents as young as 12 years old. Since 2010 the GIDS launched a trial of puberty blockers for children in their early teens with gender dysphoria. Guidelines require puberty to have begun before any intervention is agreed. This is because gender dysphoria may resolve once puberty begins. Indeed a prospective study of 77 gender dysphoric children referred to one clinic found that after 3.4 years of follow-up 27% remained gender dysphoric. Other studies suggest that nearly 90% of prepubertal GID clinic attenders who receive no intervention will eventually lose their desire to identify with the non-birth sex. However, of the children placed on puberty blockers in the Dutch clinic that pioneered this treatment, every single one of them persisted in their transgender identity. And of course, for these children who persist in their transgender identity, taking puberty blockers and then cross-sex hormones, leads to irreversible infertility.

Puberty blockers have not been certified as effective or safe in the treatment of gender dysphoria by the National Institute for Health and Care Excellence (NICE) or their manufacturers. They remain an experimental treatment, but new prescriptions were recently running at 300 per year.

Presumably there is evidence that puberty blockers work?

One might think that for doctors to prescribe such medication there is an evidence base that underpins it. After all, those of us in medicine have been trained to provide evidence-based treatment and the public should expect that treatments offered to them are safe and will improve their lives. This is where things get interesting.

A recent review by Oxford Professor Michael Biggs critiques the study instigated by the GIDS to administer experimental drugs to children suffering from gender dysphoria. He concludes that ‘it showed no evidence for the effectiveness of GnRHa…in addition, there is unpublished evidence that…puberty blockers exacerbated gender dysphoria.’ And of further concern, he found that follow up of over-18s has not been possible because ‘transgender activists successfully lobbied the NHS to provide new numbers to patients as well as to change the ‘gender’ on their medical records.’

A recent evidence review in the BMJ found ten studies that analysed the effects of puberty blockers. All lacked either significant blinding or controls, and one that included controls that ‘were inadequate as relatives and friends of the participants were asked to participate, serving as age-matched controls’.

A group of paediatricians recently wrote in the Archives of Disease in Childhood, warning that GnRHa treatment is a momentous step in the dark. They have three main concerns:

  • Young people are left in a state of ‘developmental limbo’ without secondary sexual characteristics that might consolidate gender identity. With over 90% of young people attending endocrinology clinics for puberty-blocking intervention proceeding to cross-sex hormone therapy, their use ‘may prevent some young people with GD from finally becoming comfortable with the birth sex.’
  • Puberty blocker use threatens the maturation of the adolescent mind. Puberty plays a key role in structural brain development and its delayed timing can be linked with an increase in adverse health-related behaviours and in mental health status during adolescence. It is misleading to suggest that puberty blockers are reversible. Going through a developmental process at age 20 that should take place at age 10 is not the same thing.
  • Puberty blockers are being used in the context of profound scientific ignorance. Whilst puberty blockers are used for treatment of pathological precocious puberty, it is presumptuous to extrapolate these observations to a use that suppresses normal puberty.
So why are these unproven and possibly dangerous medications being prescribed to children?

The reality is that the NHS is being overrun by increased demand, particularly in this area (see the recent resignation of a Tavistock governor in protest) and assessments are therefore done hastily without recourse to the usual ‘formulation’ (a full psychological understanding of the person in front of us).

In addition, even a cursory glance at social media tells us that fear dominates discussion of gender identity in our culture, and this has affected the medical community and the NHS. It simply isn’t true that the choice is between conversion and suicide, when at best the outcomes for those who have transitioned are no better and possibly worse than prior to surgical transition. It also isn’t wise to allow such momentous choices to be made by such young minds. Young children aren’t allowed to vote, drink alcohol, smoke or have sex because we know that the immature brain is unable to make reliably rational decisions.

Medics are trained in the rigours of evidence-based medicine. And yet, as I have heard time and time again in private, we are treating children with puberty blockers when we know the evidence is uncertain and there is potential for harm. I have no doubt that those who work in GIDS have good intentions. They are faced with difficult decisions daily and we must recognise the complexities and uncertainty that they face. The number of referrals to the service is overwhelming and many of the people we see are in real pain and looking for answers.

Is bodily sex relevant anymore?

Interestingly for the Christian, the science supports the understanding that we are embodied selves. Children do not have to create an identity or question their very core sense of self as a boy or a girl. Indeed, transgender ideology is Gnosticism re-stated – the idea that biological sex plays second fiddle to a self-proclaimed, subjective gender identity, and that the sex of one’s body is mutable or even irrelevant.

But we are allowing this ideology to drive the medical profession to experiment on vulnerable children. It is our role as medics to provide effective treatment free from external pressures. Changing bodies to conform to thoughts and feelings is at best problematic. Instead, the best treatments focus on helping people accept and even embrace the truth about their bodies and reality.

There is no well-established scientific consensus about the efficacy or safety of using puberty-blocking agents for children with gender dysphoria. It is a drastic and unprecedented measure. Further work is needed, and researchers should be permitted to ask these questions rather than being labelled as ‘politically incorrect’ or worse, ‘transphobic’.

Our children deserve treatment based on firm foundations, not on sand.

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On November 23rd a radical bill to decriminalise abortion and impose it on Northern Ireland was stopped in its tracks thanks to opposition led by Christopher Chope MP. The status quo is preserved for now – but it’s no time for us to rest on our laurels.

The Royal College of General Practitioners has just stated: “The College will now work with partners across the health sector, including the BMA, the Royal College of Nursing, Faculty of Sexual and Reproductive Health, the Royal College of Midwives and others, to call for the decriminalisation of abortion across the UK.”

A month prior to the November knock-down I’d listened wide-eyed at a pro-abortion Parliamentary meeting as Diana Johnson MP and Stella Creasy MP candidly shared their dream to see abortion fully decriminalised right up till birth. This would for example officially legalise gender-abortion – a fact which, when raised in the meeting, was neither denied nor apologised for. It would also drive abortion even further underground in terms of medical accountability. No longer would (increasingly discredited) “health” grounds be needed to grant every abortion, making it harder to prove as the tracks are covered that hundreds of thousands of specific abortions have been performed expressly on the basis of false medical information.

There was in this meeting a palpable eagerness to capitalise on the Repeal of the Republic of Ireland and rush abortion into the North, even though it is against the wishes of the Northern Irish people themselves – 100,000 of them are alive today thanks to the strong protection of the unborn currently enshrined in their law.

These twin legislative giants, representing the most aggressive advances against our unborn in recent years, are still lurking just around the corner and have only really been held off for now by little more than a political technicality. The DUP’s strong pro-life stance, combined with its position as something of a cornerstone in an otherwise non-existent majority, means that for now any such bill is unlikely to get time or support from the Government. But the abortion industry will not rest until they have prevailed, and the post-Brexit House of Commons may well be much more vulnerable. Moreover, abortion advocates are increasingly attempting to sneak it through in the form of amendments to other bills – something the DUP could be powerless to stop.

It’s almost impossible to find a single prominent Church figure in the UK who has publicly denounced abortion at all, let alone these specific and imminent threats, and some Christian doctors, whilst avoiding involvement in abortion themselves, prefer to keep their heads down rather than raise them above the parapet with vocal opposition.

Our relative silence is taken for assent – especially when it’s our taxes paying for abortions, our Royal Colleges championing them, and our British Medical Association backing full decriminalisation.

If there was ever a time for the Church and for Christian doctors to break our relative silence on abortion, it’s now.

So what holds us back?

A blast from the past might help…

In the late 19th Century, horrific atrocities were being committed against the native people of King Leopold II’s Congo Free State. Hands were cut off for the crime of insufficient rubber collection, and children were eaten by soldiers, in full view of their fellow-villagers to terrorise them.

The English missionaries there were uniquely placed to provide evidence and expose this injustice internationally, but they didn’t want to provoke King Leopold; they risked expulsion from the Congo Free State. Would it be worth it?

Perhaps we ask ourselves the same question, faced with current and threatened abortion injustice. Perhaps, like those missionaries, we consider what we have to lose – our position, our platform – and perhaps we really do believe that we need to protect these for selfless, gospel-driven reasons.

“The difficulty,” said Grattan Guinness, director of the Congo Balolo Mission at the time, “is to do good without doing harm.”

But is this cost/benefit approach to decision-making really the biblical, Christlike way?

Countless men and women in the Bible risked and gave their lives in obedience to God. Think of Joseph, Moses, Jesus, and the early Church (and later, the Reformers). They didn’t stop to wonder whether it would be “worth it”. They simply obeyed God and left the outcome to him.

Remember the words of Esther confronting the King about the plot to exterminate the Jews: “If I perish, I perish.” She understood that her platform, and even her life, were not for protecting: they were for using and if necessary for using up, “for such a time as this”, in the cause of something greater.

If engaging with issues of justice is a command of God, there are in fact only two possible paths – obedience, and disobedience.

It’s hard to think of a harassed people group more numerous, more vulnerable, and more unable to speak for themselves, than unwanted babies in the womb.

The unborn is our neighbour, and we are commanded to love our neighbour as ourselves.

Can there be any question over the biblical mandate to defend the unborn?

Whenever we allow God to back the security of our job or mission field but disallow him from speaking through us about justice, we make God in our own image and engage in a form of idolatry.

Thankfully the CBM did come out publicly against the Congo injustice in 1903, a year before the Government’s Casement Report, with the help of the newly invented Kodak, turned the political tide.

I wonder how history will look back and judge us. Will they see men and women who stood up whatever the cost? Or will they see men and women who loved their own lives?

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, : “Ultimately, this is about providing non-judgemental care to our patients so that women who face the difficult decision to proceed with an abortion are not disadvantaged by the legal system.”

When faced with a pregnant woman, she sees only one patient. But we see two, and as doctors, and as Christians, we have a duty to protect both.

Decriminalisation, and abortion in Northern Ireland: these giants will make another attempt, and soon.

Will we wait for them? Or shall we go on the front foot, go on the offensive, and “speak up for those who cannot speak for themselves“?

Dave Brennan, founder and leader of Brephos

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Surrogacy is often portrayed as a compassionate and beautiful act, a selfless gift, where a woman carries a child for a couple or an individual who are unable to have their own children. On the surface it appears to be a great act of kindness. However, beyond the superficial, there are troubling aspects of surrogacy arrangements that should not be skimmed over.

The law around surrogacy in the UK is currently under review. This review is being carried out by The Law Commission of England and Wales, together with the Scottish Law Commission, and a consultation paper is expected to be released by Spring 2019.

It is interesting to see how perceptions of surrogacy have changed over the last 40 years. Described as ‘irresponsible, bizarre and unnatural’ by a judge at the Court of Appeal in 1978, now it is recognised as one of many viable options for starting a family. This is reflected by an increase in the number of parental orders issued after surrogacy arrangements – 194 parental orders in 2012, rising to 368 in 2016.

Why do people opt for surrogacy?

Some women  have medical conditions that render them unable to carry a child. There are a growing number of LGBT+ couples seeking to have children. There are single people who long to fulfil their dream of becoming a parent. There is also the worrying trend of ‘social surrogacy’ in America. Even going as far back as the Old Testament, we read of Sarai trying to build a family through her maidservant Hagar, and of Rachel using her maidservant Bilhah to bear children for her.

Who benefits from surrogacy? Whose interests are we acting in? Is it the child’s, or the parents’?

When a couple or an individual commission a surrogate to carry a child for them, are they not trying to fulfil their own desire to be a parent? It cannot be denied that there are many people in the UK who desperately long to have their own child, who experience sorrow and heartbreak because they are unable to achieve this. This grief should not be ignored or coldly cast aside. Yet in our society, the principles of autonomy, personal choice and individual rights are almost sacrosanct. If medicine and new technologies can enable a couple or individual to have a child, why shouldn’t this be allowed at any cost? These questions are not easy to answer.

Legislation regarding surrogacy arrangements in the UK is based on the ‘Surrogacy Arrangements Act 1985’. Despite being updated by the Human Fertilisation and Embryology Acts of 1990 and 2002, legislation has been branded as ‘not fit for purpose’ and ‘restrictive’. The Law Commission has highlighted three areas of law it wants to review: the issue of legal parentage when the child is born, international surrogacy, and the regulation of surrogacy arrangements (ie. the question of payment for surrogates).

However I believe that we should be wary of modernising the law or of abandoning the safeguards that are currently in place.

At present, ‘altruistic’ surrogacy arrangements are legal in the UK. In these cases, only expenses ‘reasonably incurred’ are remunerated, with the precise amount case-dependent. The Department of Health explicitly states that ‘Money should not be a motivation for surrogacy’. In ‘commercial’ surrogacy arrangements the surrogate is paid for the ‘service’ she provides (carrying and delivering the child).  Commercial surrogacy, along with any form of surrogacy advertising, is illegal in the UK. And yet even in the so-called altruistic surrogacy agreements, vast amounts of money can often change hands – typically, a surrogate in the UK will be paid £8,000 – £20,000. Regulation differs in other parts of the world, with commercial surrogacy being legal in several countries including Ukraine, Georgia and parts of the USA.

There is a worrying drive to commercialise surrogacy arrangements in the UK. Why is this concerning?

First, commercial surrogacy opens the door to manipulation and  abuse of women. Surrogacy has been described as ’a form of exploitation of women and children as it reduces the woman to a reproductive machine and the child to an asset in a business transaction.’ A surrogacy arrangement is a contract between ‘commissioner’ and ‘service provider’. Typically, the commissioner is a wealthy couple or individual who desires a child and has the means to pay for one – to ‘rent a womb’ (this phrase captures the concern well, as well as being starkly accurate). The ‘service provider’, often poor, is attracted by the promise of financial reward. Traditionally, India was a popular destination for ‘fertility tourism’. However, in December 2018 India passed ‘The Surrogacy Bill’, which forbids commercial surrogacy and forbids any foreign nationals from using an Indian woman as a surrogate. It is striking that a country which has experienced first-hand the devastating effects of commercial surrogacy has taken such radical steps to end it, in order to protect impoverished and vulnerable women from exploitation.  The terms ‘service provider’ and ‘gestational carrier’ reflect the way that women (mothers) are reduced to consumer products.

Second,  , the review will look at making surrogacy arrangements legally binding contracts. This will mean that the ‘commissioning parents’ would become legal parents at birth. At the moment surrogacy arrangements  are not based on a legally binding contract, so that the legal parents at birth are the surrogate mother and, if she has one, her partner. The surrogate (birth) mother is not obliged to give up her child; under current legislation her rights are protected. Instead, a ‘parental order’ is used to transfer the status of parenthood from surrogate to commissioning parents six weeks after the birth. As of January 2019, single people are also eligible to apply for a parental order.

Astonishingly, it is now possible for a newborn baby to have six individuals each with a claim to parenthood. First there is the surrogate mother and her partner. Second, there is the ‘commissioning couple’. Finally, there may be an unrelated egg and/or sperm donor. Who has the most legitimate claim? Why shouldn’t the commissioning parents be the legal parents from the moment of birth?

Advocates say this would protect the commissioning parents in case the surrogate mother changes her mind and wants to keep the baby. However, the woman who has carried the baby through the nine months of pregnancy has intimately known and bonded with the baby in a way that no one else could. In separating herself from the child at birth, she is forced to repress her emotions and the maternal instinct to love, cherish and nurture the child. Could it not be said that to force this mother (even if in legal terms she is only a ‘gestational carrier’) to give up this child is unashamedly exploitative?

Third, the needs of the child must be considered.

We are told in Proverbs 31:8-9 to “Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy”. Surely the newborn child comes under the category of one who cannot speak for themselves, as one of the vulnerable members of society. We are called to defend such a person, to stand up for his or her rights. Surely the most fundamental right of the child is to be with the person who is generally most able to satisfy his or her needs ie. the mother.

This CMF file is a helpful resource for thinking through biblical principles in more detail. God has given us the ability to develop all kinds of technological innovations, and it is good to use these to achieve his redemptive purposes in the world. Yet just because we can produce a child in this way, does that make it morally right to do so?

Every child born from a surrogacy arrangement (or indeed using any form of reproductive technology) is uniquely designed by God and valuable to him. We are told in Genesis 1:26-27:

“Then God said, “Let us make mankind in our image, in our likeness…” So God created mankind in his own image, in the image of God he created them; male and female he created them.”

Every child, whatever the circumstances of their birth, has a status and dignity that cannot be removed. Yet in surrogacy arrangements, which are driven by money, it seems that children are no longer viewed as God’s image-bearers, but as commodities which can be purchased – bought for a price.

Throughout the ages, childlessness and the inability to conceive has been a devastating reality for many, leading to anguish and grief and many tears. In an age of self-fulfilment where anything seems possible, it seems harsh to say that seemingly restrictive safeguards may just be what our society needs.

Without doubt, great wisdom and compassion are needed.

Kelly Hibbert is a junior doctor

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The Royal College of Obstetricians and Gynaecologists (RCOG) has produced a new factsheet on abortion to support Relationships and Sex Education in secondary schools. This ‘aims to ensure that professionals involved in educating young people on abortion do so ‘…with honest and medically accurate information…[which] distinguishes between fact and fiction.’

Since this new factsheet is likely to have very wide circulation and use within schools, I want to take a closer look at it, to see if it holds up to its claims for honest and accurate information.

‘Abortion is extremely safe in a UK setting’ (p6)

However there is no mention of studies that show significantly increased mortality rates among women in the ten years following abortion [see here, here, here, here, here and here]. Some of these studies involved over a million women over a 25-year time period.

‘There may be a slightly higher risk of future premature birth’ (p6)

However the risk of future premature birth is understated [see here]. The link is backed up by over 119 studies,. including a major British study involving more than half a million women over 26 years in Scotland. This short briefing notes several other robust studies that similarly demonstrate an increase in the risk of preterm delivery after abortion, a risk that increases with the number of abortions that a woman has.

‘Abortion does not increase the risk of breast cancer’ (p6)

The evidence on this is controversial. The RCOG cites a large meta-analysis, but ignores conflicting meta analyses [see here and here]. Further research is needed to settle this issue but, in the meantime, women have a right to know that there is ongoing scientific debate about the risks.

She should be offered non-directive counselling’ (p6)

However the majority of pre-abortion counselling continues to be carried out by the abortion providers themselves, who only benefit if the woman chooses to proceed with her abortion [see here, here, here and this CMF blog].

‘Abortion does not cause mental illness’ (p7)

Philippa Taylor covers this in more detail here. The RCOG references a major review from 2011 but ignores independent evidence suggesting that women may be at increased risk of mental health disorders following abortion, even with no previous history of problems [see here, here and here]. As before, further research is needed, but in the meantime school children should not be taught such headlines as proven scientific truth.

‘The fetus is unable to feel pain under 24 weeks’ (p7)

As well as being contradicted by professional practice ‘at the sharp end’ (NHS surgery on babies at 20 weeks’ gestation uses fetal painkillers), the RCOG’s conclusion in their 2010 paper hinges on whether the cortex is necessary for pain perception; an assumption based upon three citations [see here, here and here], none of which support the claim. In fact, the third study actually contradicts the RCOG’s own conclusion and instead indicates that pain perception is rooted in the thalamus which, according to their own paper, begins to be connected ‘between 12 and 18 weeks’ [p8].  Some studies have found evidence for the possibility of fetal pain at 15 weeks gestation. See here too.

Despite claiming at the outset that their factual information is needed to address ‘myths and misinformation’, which is an admirable aim, I and others are concerned that this new factsheet presents some inaccurate and misleading information about abortion to secondary school pupils.

Does the Department of Health and Social Care exercise due diligence in oversight over the RCOG’s publications? Will the Department of Education check the facts presented? They would be welcome to check CMF’s own factsheet  Abortion: Risks and Complications which can be found here.

For now, I might even go so far as to say this RCOG factsheet is a modern-day example of the well-worn propaganda principle: make the lie big, keep it simple, keep saying it and eventually people will believe it.

James Evans is a biology teacher with a background in genetics

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A new factsheet produced for schools by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual and Reproductive Healthcare (FSRH) states as one of the ‘myth buster‘ headlines that ‘abortion does not cause mental illness’.

Underneath the headline they explain: Successive studies and research reviews have demonstrated that the experience of abortion makes little or no difference to women’s mental health.

This ‘myth buster’ headline needs some myth busting.

The question of whether abortion is linked to mental health problems in women is very important and has long been a debating point. Journalist Caitlin Moran made the following astonishing claim about the effects of abortion her regular Saturday Times column on 23February  2019:

‘Since legalisation, 8.7 million safe, legal terminations have been carried out – and there is not a single survey or statistic  that shows any negative impact from this. If you want to point at the downside of legal abortion, you cannot do it using any evidence.’ (her emphasis)

I would hope that even the RCOG might have some objection to Moran’s false claim. The RCOG cite a well-known, NHS funded, review of abortion and mental health in their fact sheet, a review that quite clearly states there are some negative mental health consequences from some abortions.

So is the RCOG correct to say ‘Abortion does not cause mental illness?’ What does peer reviewed evidence show?

Assessing the effect of abortion on mental health is complex and controversial and findings are frequently conflicting. Even though studies may show an association or link between abortion and a subsequent health effect, the way that studies are designed mean that we cannot always be certain that the abortion definitely causes the health effect. It is simply not possible to conduct a randomised controlled trial assigning some women to an abortion group and others to a birth group.

One problem with even some of the best known and most widely cited research studies is choosing what groups to compare with women who have an abortion (Women who have had a miscarriage? Given birth? Women who have never been pregnant? With an intended pregnancy or not?) because there is no direct equivalence. Then there is selection bias (many studies have high drop-out rates and low recruitment rates) because those who are least likely to participate will be those most affected negatively by the abortion. And many studies simply fail to follow up women long enough after the initial study – often women cope well initially, but years later reappraise the abortion negatively.

So, reviews of the psychological effects of abortion have arrived at disparate conclusions.

However as noted above, there was a comprehensive, NHS funded, review into the mental health outcomes of abortion, carried out in the UK in 2011, which the RCOG reference, and this found that having an unwanted pregnancy is associated with an increased risk of mental health problems. However, it found that the rates of mental health problems for women with an unwanted pregnancy were the same, whether they had an abortion or gave birth. In other words, abortion made no difference to the outcome.

It appears then, that the RCOG fact sheet sub-heading may be correct, according to this review.

But it is not quite so simple.

The review also found that women who have mental health problems before an abortion are at greater risk of mental health problems afterwards. And it found that several other factors such as stressful life events, pressure from a partner to have an abortion, a negative attitude towards abortion in general and a negative emotional reaction immediately following an abortion (which are all common feelings), also have a negative impact on mental health.

So, for these women, it suggests abortion is a risk for causing mental illness.

Prof David Fergusson, veteran research in the field who said he was not ‘pro-life’ and is cited in the review, published a number of his own peer reviewed papers on abortion. He found small to moderate increases in risks of some mental health problems post-abortion.  See here for more of his research, in the British Journal of Psychiatry, 2018.

A brief but important aside here, Fergusson also noted that no study has reported that abortion reduces mental health risks.

There is a growing body of evidence that suggests that women are at an increased risk of mental health disorders, notably major depression, following abortion, even with no previous history of problems. Researchers not associated with vested interest groups have published this growing scientific evidence. As well as Fergusson, Pedersen and Broen have found similar links in Norway, along with Mota in the USA.

Then there are researchers who are known to be more ‘pro-life’ who have also published extensively in academic journals on this topic for many years. See for example Sullins, Reardon, Rue and Coleman (summarised here). Coleman’s findings suggest a clear link between abortion and adverse mental health effects. She found that nearly 10% of all mental health problems are directly attributable to abortion, and women with an abortion history experience nearly double the risk of mental health problems when compared with women who have not had an abortion.

Coleman’s work has strengths and weaknesses. It was published in the British Journal of Psychiatry, passing extensive scrutiny, and is a meta-analysis of 22 published studies, with nearly 900,000 participants. However, it has several methodological weaknesses that have been criticised by researchers who have come to different conclusions.

Yet Fergusson, who described himself as a pro-choice atheist, defended Coleman and concurs with her overall finding: ‘There is a clear statistical footprint suggesting elevated risks of mental health problems amongst women having abortions.‘

Women – and now school girls – are being told that abortion is an emotion-free, quick and safe process requiring a simple operation or a couple of pills. They are entitled to be told that it is more significant than this and that there is evidence (despite the claims of Caitlin Moran) for associated mental health risks. Moreover, many women who present for abortion are ambivalent which is a known risk factor for later adverse effects.

For those still not persuaded by the research evidence on the link, perhaps a visit to a local crisis pregnancy centre, or a read of some of these stories of women who have undergone an abortion might help bust the myths.

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A recent legal ruling in Canada is a strong warning for British medical professionals who conscientiously object to involvement in abortion, or who would do so with assisted suicide if it were ever legalised.

In 2018 the Ontario Superior Court ruled that healthcare professionals who refuse to carry out abortions (and euthanasia) must refer patients to doctors who will do so:

The ruling means that doctors will be required to do such things as sign abortion authorisation forms, provide preoperative care or refer patients to another doctor who will do any of these things, and more. Many clinicians quite understandably will equate these acts morally with actual participation in the procedures objected to.

The Ontario court’s decision comes in the wake of Canada’s decriminalisation of abortion in 1988 (R v Morgentaler). Since decriminalisation, abortion has been treated as a purely medical procedure under federal Canadian law.

The situation is Canada is now highly relevant for UK healthcare professionals, as a bill to decriminalise abortion in England and Wales has been debated and voted on in Parliament. Sponsored by Labour MP Diana Johnson, the decriminalisation of abortion bill passed its first reading in the House of Commons in October 2018. It failed to pass second reading and is unlikely to progress any further in this current session. However other attempts will be made to decriminalise abortion in the England and Wales and Northern Ireland using different strategies. Like with Canada, decriminalisation here would treat abortion purely as a medical procedure and leave us with one of the most extreme abortion regimes anywhere.

Whilst the Johnson Bill retained the right to conscientious objection provided for under current British abortion law, subsequent attempts to remove or qualify that right could easily result in UK doctors being placed in the same position as those in Ontario.

It is important to note that the Ontario case merely confirmed what a respected medical professional body, the College of Physicians and Surgeons of Ontario (CPSO) had already stipulated as policy.

In 2015 the CPSO updated its Professional Obligations and Human Rights policy to read:

‘Where physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another health-care provider must be provided to the patient.’ (my emphasis).

The policy stipulates serious penalties for those who do not comply.

That the Canadian medical body produced such a policy is noteworthy for the British medical community: the Royal College of General Practitioners has recently announced its support for the decriminalisation of abortion.

In Ontario, five doctors and three organisations, including the Christian Medical and Dental Society of Canada launched a legal case against the CPSO in order to challenge the referral policy

The plaintiffs told the Ontario Superior Court that the CPSO policy breached doctors’ rights to freedom of religion and conscience under the Canadian Charter of Rights and Freedoms, and that referral was tantamount to being forced to participate in the procedures.

However, in its highly concerning ruling the Court stated: ‘The applicants do not have a common law right or a property right to practise medicine, much less a constitutionally protected right.’

‘Those who enjoy the benefits of a licence to practise a regulated profession must expect to be subject to regulatory requirements that focus on the public interest, rather than the interests of the professionals themselves.

Admitting there was a breach to doctors’ rights, the Ontario court said this was justified, as the cost to doctors, who do not have to work in areas where such questions arise, is less than the benefits to the public. If doctors were allowed to exercise their Charter conscience rights in this way, the court said, ‘a real risk of a deprivation of equitable access to health care’ would be established.

The plaintiffs determined to take the case to the Supreme Court of Canada in appealing the Ontario decision. The Court heard the appeal in January 2019.  At the time of writing, the Canadian Supreme Court is considering its ruling and a decision is awaited. Although Canada is different in several respects, it has a common law jurisdiction and many arguments deployed there are brought in over here. Hence the Canadian situation presents a stark warning to UK doctors, let alone nurses and midwives who already have fewer protections for freedom of conscience here.

At a time when medical professional bodies here – and in Canada – are pushing an agenda of abortion and euthanasia, there remain those who object to this and who are pushing back in favour of life and care, not killing.

Karen Faulkner is a Christian writer and British law graduate. She has a Master’s degree in Human Rights and Transitional Justice.

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The eighteenth century philosopher, Jeremy Bentham, wrote of animals: ‘The question is not Can they reason?, not Can they talk?, but Can they suffer?’ Professors Glover and Fisk, in their 2005 paper ‘Fetal Pain: Implications for research and practice’ say that this caused a change in attitude towards animals and their treatment that is continuing today, so that in the UK, even frogs and fishes are required by Act of Parliament to be protected by anaesthesia from possible suffering due to invasive procedures. So why not human beings?”

Within the living memory of some clinicians, medical students were taught that unborn babies didn’t feel pain.

It was in the mid 1980s that Professor ‘Sunny’ Anand raised the issue of fetal pain. The then David Alton MP raised the issue in parliament in 1988 and subsequently established a Commission of Inquiry with CARE on Human Sentience Before Birth. It still took until 1997 for the first official investigation by the RCOG which recommended that those carrying out diagnostic or therapeutic procedures on the fetus in utero at or after 24 weeks should consider the need for fetal analgesia – notably specifying diagnostic and therapeutic procedures, and omitting terminations. After the Science and Technology Committee’s paper on abortion in 2007, the Department of Health commissioned a review by RCOG which was published in 2010.

This RCOG report remains in place as the official position on fetal awareness.

The report, however, immediately drew both national and international criticism, including that of Peter Saunders the then CEO of CMF [here, here and here], for, among other things, its assertion that a fetus remains in a permanent unconscious state and does not reach consciousness until birth. This conclusion continues to contradict the established understanding of scientific and medical literature on life in utero (see here, para 4).

The assertion that the fetus does not have consciousness is based on, in the words of the RCOG 2010 report: ‘good’ and ‘increasing’ evidence. However their citation is one paper from 1986 which was an experiment on sheep fetuses exposed to low oxygen levels. This, needless to say, comes nowhere near the tissue trauma of a surgical procedure in utero. On this basis, mothers have been assured that there is no need for fetal analgesia during an abortion or fetal surgery, at any gestational age.

However, it now seems the Department of Health has now done a U-turn despite maintaining their denial of fetal pain, even up to January 2019.

Following an announcement that fetal surgery to address spina bifida in utero will be made routinely available on the NHS, the Government was asked about fetal pain relief in such cases. In response, a written parliamentary answer 14 February, states that:

‘Pain relief for the unborn baby will be delivered intra-operatively. This is administered before the fetal surgery, after the uterus is opened…The surgery takes place between 20 and 26 weeks of gestation.’

During these same gestational ages in England and Wales last year 3,564 unborn babies were aborted without pain relief, mostly by dilation and evacuation (D&E), a ‘dismemberment’ abortion, where, in the words of the RCOG ‘the fetus is removed in fragments’ or by injecting the unborn baby’s heart with potassium chloride which, according to BPAS ‘can take several hours for the fetal heart and movement to stop’.

No doubt in the coming weeks, the Government will be asked to extend its use of fetal painkiller to all invasive procedures in utero, including terminations. But from what gestational age will they consider and will they err on the side of caution? Some studies have found evidence for the possibility of fetal pain at 15 weeks gestation. There is still enough time for the current NICE Consultation on Terminations, which is due to be published later on this year, to amend current advice that fetal analgesic such as fentanyl be given prior to a late term abortion. The Department for International Development, who rely on the RCOG for their abortion guidance, should also consider funding for fetal painkiller for late term abortions that we fund overseas.

There is also still time for clinical guidelines to be amended in the Republic of Ireland for late term abortions. It was only a few months ago that, to their shame, in the Dáil members of the Irish Parliament laughed at the suggestion of fetal pain relief and the amendment was dismissed apparently without having checked for evidence.

Additionally, there must be extra support offered to mothers and relatives who trusted and followed the Government advice that their unborn baby will not feel a thing. Even without an official response, there are excellent charities in the UK who specialise in post abortion counselling such as We Are Open, Rachel’s Vineyard and ARCH.

So, after three decades of lobbying by clinicians, mothers, politicians and pro-life groups, the Department of Health now recognise fetal pain and recommend the use of fetal analgesia from at least 20 weeks gestation – a victory for both women and their unborn babies. However, in doing so, they unearth a truth that RCOG has spent thirty years denying, covering up and burying.

Surely in order to achieve the best patient care and to restore trust, the way forward now is for a comprehensive, fully transparent review around fetal awareness by a multidisciplinary team that includes expertise in paediatrics, fetal surgery, neurology and anesthesia. Having established the scientific evidence, they should use this to inform a compassionate clinical approach and recommend a start point for fetal analgesia that errs on the side of caution.

James Evans is a biology teacher with a background in genetics

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Medicine has held a long-established opposition to assistance with suicide.

Ira Byock, an American Palliative care physician, believes this is necessary so that:  ‘the power of medicine is not used against vulnerable people’. One of the roles of medicine is the need to balance our duties to the individualwith our duties to society. This is particularly challenging when societies around the world are changing (with a small number of countries permitting assisted dying) and when those wanting change are themselves from within the medical profession.

However, the UK has been resistant to a change in the law which may be because the UK is the birthplace of modern palliative care that affirms death as a natural process and intends neither to hasten nor delay it. In fact it has been argued that palliative care and assisted death are not compatible with each other.

Against this background the Royal College of Physicians (RCP) has taken the controversial step to ‘adopt a position of neutrality’on the issue of ‘assisted dying ‘ (an umbrella term that has been taken on by assisted suicide advocates but which has no meaning in law and refers to the more accurate term, assisted suicide and euthanasia.).

The RCP has stated that ‘neutrality means the RCP neither supports or opposes a change in the law’ and that by ‘remaining neutral it can reflect the differing views of its fellows and members in discussion with government and others’.

The RCP’s announcement has created a lot of controversy; the framing of their poll of members is highly irregular  and for many assisted suicide is not something that a medical body can be neutral on.

There are (at least) three reasons why the RCP’s assertions are highly disingenuous, and concerning:

  1. ‘Adopt a neutral position’. The RCP is currently opposed to assisted dying. So, this would be not so much the ‘adoption’ of a position but moving away from the established position of opposition. This act of movement is highly significant in and of itself. In the Canadian Supreme Court case of Rodriguez in 1993 it was identified that there had to be a change in either legislative, medicalor societal views in order to cross the current line of prohibition of assisted dying.

If we accept figures from organisations such as Dignity in Dying (figures that have been challenged here and here) then it would seem, that in the UK, superficial societal support for change has been consistently high. Yet in spite of this Parliament overwhelmingly rejected an attempt to change the law in 2015. With society and Parliament, in effect, ‘stuck’ any movement by the medical profession will be grasped by pro assisted suicide lobbyists as the window of opportunity needed to push for change. This is made evident by Dignity in Dying  ‘welcoming’ the RCP position of neutrality. Also, the RCGP poll of GPs in 2014 found that many of the doctors who voted neutral did so because they wanted to see the law changed. One could argue the college is playing into the hands of pro assisted suicide pressure groups who will use the new ‘neutral’ position to change the law.

  1. ‘Neutral neither supports or opposes a change in the law’. Sadly, evidence already exists that ‘neutral’ is a dangerous stance when the profession does not know the details of the legislation being proposed. In Oregon the medical association went ‘neutral’ six months before the public vote that brought in a new law permitting assisted suicide. This law, known as the Oregon Death with Dignity Act, allows terminally ill Oregonians to self-administer lethal medication prescribed by a doctor (see a blog on this here). Altmann and Collins in their 2007 analysis of the Oregon Death with Dignity Act identified that at the time legislation was being drafted the strongest input came from the politically active, unified and well-resourced voices of pro lobbyists, they make note of the fact the medical association was neutraland those opposing also had little impact. The Oregon Medical Association (OMA) went on to declare the draft bill as ‘deeply flawed’and supported its repeal (as recorded in the OMA house of delegates annual meeting, 2005) but it was too little too late, and the bill was enacted after a second public vote in 1997.

In Canada the Canadian Medical Association (CMA) went ‘neutral’ before the ground breaking Supreme Court decision in the case of Carter in 2015. This case paved the way for assisted suicide and euthanasia in Canada which became available in 2016. The CMA policy contained the so-called ‘neutral’ statement that the CMA‘supports the rights of patients to have access to all legal end of life options’. This ‘neutrality’ has been described as providing a blank cheque for the Supreme Court of Canada to legalize euthansia and physician assisted suicide on any terms acceptable to the judges. Since this decision, the medical profession has been told that not only will it be integral to development and provision of assisted suicide and euthanasia but it should also recognise that the voice of the physician should be just one among many.

It seems wholly foolish for the RCP to agree a position of neutrality ahead of any knowledge of what legislation is planned. It is tantamount to binding the profession’s hands. Indeed this is exactly what the BMAfound when it went neutral for one year; their ability to engage in discussion was hindered and they returned to a position of opposition so they could be in a position to intervene and advocate for safeguards.

  1. ‘Allows the college the ability to reflect the differing views of its members’: In the UK assisted suicide is illegal; it is strange logic and an abdication of responsibility to suggest the purpose of the RCP is to reflect views contrary to the current law without having a specific view itself. The Canadian Medical Association has identified ‘neutrality’ as a ‘third way that supports all its members’. But one of the key challenges after the Carter judgement was to ensure there are doctors willing to provide ‘medical assistance in dying’. However, intentional killing is not something the majority of doctors want to do. For example, in Oregon 92 doctors prescribed lethal medication out of a pool of 11,500.  Canadian doctors who did not want to be involved in euthanasia or physician assisted suicide discovered that the CMA was slow to respond to concerns about freedom of conscience  against moves by state regulators to compel physicians to act contrary to their values. The CMA’s policy of neutrality meant that when assisted suicide and euthanasia were legalized, its ability to ‘support all its members’was in conflict with its policy to support access to the provisions of the law. The RCP must learn lessons from Canada, arguably it is opposition to change, and not ‘neutrality’, that provides an organisation such as the RCP the best opportunity to fight for protections for all its membership.

The RCP seems to think ‘neutral’ represents non-judgemental support of all views both in its membership and society. But it has a duty, beyond appearing equitable, to protect the interests of its membership and society. With its current plan to move to a so-called ‘neutral’ stance on assisted dying it risks actively weakening its ability to provide this protection.

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The Royal College of Physicians (RCP) is going to poll its 35,000 members to ask whether ‘they would help a terminally ill patient to die and whether the law should be changed to allow assisted dying.’

I should first clarify one point from the draft question above. The term ‘assisted dying’ is a euphemism. It has no meaning in law but it means supplying lethal drugs to people who are terminally ill with the purpose of helping them to commit suicide. At the moment, the RCP opposes it. And the reality is that assisted dying is just another form of euthanasia.

However the problem for those within the RCP who support a change is that in their last poll of members, five years ago, 58% said they would not participate in ‘assisted dying’, a similar number to a 2006 poll and, as the press release admits: ‘Five-years ago, a similar survey found that a majority of respondents did not support a change in the law.’

Very cleverly, the RCP now say that they will go officially neutral on the law unless a full two thirds of members oppose this!  ‘The RCP will adopt a neutral position until two thirds of respondents say that it should be in favour or opposed to a change in the law.’ (my emphasis).

So, what is my worry about going officially ‘neutral’?  Does it not simply mean that doctors can just sit on a fence and not dictate to others what they should or should not do?  Neither supporting or opposing. That seems perfectly reasonable in this age of individualism and personal choice.

However neutrality is a murky concept. In this case, declaring oneself ‘neutral’ on the subject is equivalent to watching and standing by while someone jumps off a bridge or into a train. Logically, neutrality implies that ‘we are no longer opposed’.

Rather than saying ‘I’ll help you kill yourself’, ‘neutrality’ from a doctor signals that ‘I don’t care if you kill yourself’.

It is impossible to be neutral about doctor-assisted suicide, as Sulmasy and Baroness Finlay argued cogently last year in the Journal of General Internal Medicine. The political effect would be to give it a green light. It would send the signal that there is no serious problem with doctors prescribing lethal drugs so their patients can kill themselves. Yet doctors have no business pretending to be ‘neutral’ about matters of life and death. This is at the heart of their profession. It is not an issue for indifference. They have to take a stand and if they do not oppose assisted ‘dying’, they in effect support it.

Michael Cook warns that: ‘The call for “neutrality” is a clever way to breach the defences of opponents of assisted-suicide and euthanasia. In the lead-up to World War II, Denmark, Norway, Belgium, the Netherlands, Luxembourg, Lithuania, Latvia and Estonia were all neutral. And then, suddenly, they weren’t.’

Moreover, if ‘neutral’, doctors would not only abdicate moral responsibility for their own patients but they would have to stand by and have no influence in any public debates: ‘‘Neutral’ means the RCP neither supports nor opposes a change in the law and can reflect the differing views of its members and fellows in discussions with government and others’. As Steve Fouch ‘The RCP will be forced to remain silent and take no part in any debate. Physicians would have no collective voice’.

The RCP represents doctors from across a spectrum of thirty specialities and is the oldest and one of the largest and most influential medical colleges in the world. Their influence on this matter should not be underestimated. A position taken by such a leading College will have political and social consequences that will reverberate far beyond their own members.

By tipping the scales in favour of so-called ‘neutrality’ the RCP’s position has itself become far from neutral. And is moving away from the fundamental duty that doctors should always care and never kill.

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