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PSYCHIATRIC INDICATIONS FOR TERMINATION OF PREGNANCY
Saturday PSYCHIATRIC INDICATIONS FOR TERMINATION OF PREGNANCY* R. F. TREDGOLD M.A., M.D. Cantab., D.P.M.
SOME psychiatrists and gynaecologists feel that pregnancy should never be terminated on psychiatric grounds. Other psychiatrists, on the other hand, are prepared to recommend abortion in a majority of the cases they see,
and many gynaecologists are prepared to act at once on their recommendation. Similar differences are seen in the views of general practitioners, patients, and the public (who, of course, include patients’ relatives). Wide ranges of opinion are not unusual among doctors, and in general are healthy enough: they lead to arguments which, though they may be heated, seldom last long, and often allow the development of a body of opinion which discards the exaggerations of both sides. On some subjects, however, disagreement is more violent and lasts longer, often leading the protagonists to attack not only the opinions but also the integrity of their opponents. This is more characteristic of political or religious than of scientific controversy; and we know, of course, that abortion raises ethical and religious problems. three questions are much debated. First, has the foetus a soul ? Secondly, if it has, what happens to this soul if the foetus dies unbaptised ? and, thirdly, when does the foetus become a " person " and at what stage does termination become murder ? To this last question the most general reply seems to be, at quickening. This occurs at different times in different pregnancies but has the advantages of being recognisable by the mother, and of corresponding, roughly, with the recognition of the fcetus as a human being by the theatre staff. Until recently pregnancies were terminated before quickening; but, now that some gynaecologists prefer to operate at sixteen weeks, the emotional strain on the theatre staff will be greater. It is already severe, since gynxcologists and nurses involved in termination are asked to destroy life rather than to save it, as they have been trained to do. Indeed, we can sympathise with the gynaecologist who said that if psychiatrists recommend abortion they should learn to do it themselves (though this I would oppose on many grounds). We can have even more sympathy for nurses, who can scarcely refuse to do what they are told by gynaecologists and often cannot voice their reluctance. The State of the Law
Apart from these uncertainties, many people are not clear about the state of the Law in this country-still less about its state elsewhere. It is widely believed, for instance, that termination is much easier to get in Sweden; this is by no means true, for the Swedish criteria, though different from ours, are stringent. Many mothers or would-not-be-mothers have taken a plane to * Maudsley Bequest lecture given at the Royal Society of Medicine, on Feb 11, 1964. 7372
I2
December I964
Stockholm, with or without their doctor’s recommendation, to return still pregnant. It is not easy for a doctor to be sure of the Law; and I recommend those who wish to follow the legal arguments in detail to read the writings of Dr. Glanville Williams (1958). Briefly he holds that the findings of two wellknown cases, Rex v. Bourne, and Rex v. Bergman and Ferguson, have provided enough precedent to establish that if the doctor terminates, or recommends termination in good faith, to save the mother’s life, or prevent serious injury to her health-the phrase is " to prevent her becoming a physical or mental wreck "-he is within the law. Dr. Williams says: Some doctors are afraid that the decision in the Bourne case will be reversed in some future case in which they themselves are prosecuted. It may be safely said that this fear is unfounded. It is true, some other judge might refuse to follow the direction in Rex v. Bourne, and his decision might be upheld by the court of Criminal Appeal. Every lawyer knows this is
only
"
not a
practical possibility."
To me this seems clear enough, but not everyone has read it. The difficulty, of course, lies in deciding whether or no the woman’s life or health is in danger; and this is partly because of the way in which she presents herself to the doctor. The Scene at Consultation The different types of patient, and the way they come, were well described by a psychiatrist in the Observer for
Nov. 24, 1963: are remarkably varied. The woman unmarried, or the mother of a large family at the end of her tether; she may have been the victim of rape, or seduction under drugs; she may have had a series of sexual affairs with little forethought or self-control, or be a young wife taking every contraceptive precaution to postpone pregnancy. She may have been in contact with an infection, or a drug,
" The circumstances
may be young and
that makes her believe her child will be a monster, or she may that this is so; she may have religious views against abortion, or glory in free-love, even if she deplores its consequences as’unfair to women’; she may be a career woman, or be mentally subnormal; she may be entirely without help, or supported by a loving family.... She may be depressed; angry with the father, with herself, and anyone else who won’t do what she wants; anxious, pathetic, courageous or defiant. She may consciously exaggerate her symptoms."
pretend
These situations will certainly arouse different reactions in the minds of those who hear the story-relative, nurse, general practitioner, gynaecologist, even psychiatrist. One may feel entirely sympathetic with the victim of rape, or with the mother of seven who realises that her eighth child is likely to be a thalidomide baby; one may feel irritated by an admittedly casual amateur who has taken no precautions; or one may feel counter-aggressive to a defiant girl whose anger (with herself) is vented on all Of course, the psychiatrist is helped by his comers. to understand, and at least allow for, his own training natural reactions; but perhaps he is not always as successful in doing so as he thinks. And it is wise to
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remember Becket’s temptation in T. S. Eliot’s masterpiece : to refrain from doing the right thing, simply because there is a wrong reason for doing it-and because it might seem (to others) that this was why it was done. Collection of Evidence
Enquiries into Maternal Deaths in England and Wales’ shows that, if illegal abortion is as common as it is supposed to be, the risks to life involved cannot be much more than in normal childbirth, in which the maternal mortality rate is now regarded as very satisfactorily low. " It would seem therefore either that the professional competence of criminal abortionists has been very seriously underrated, or else, and surely more probable, that their numbers have been much exaggerated."
There are other difficulties. The situation is one of the few in medicine when the patient may have an interest in deceiving the doctor; and doctors do not like that, which is a further emotional complication. But even the I am not sure that I share Dr. Goodhart’s opinion as to entirely honest patient may not be able to give a very which is the more probable of these two. objective account of the changes in her mental state Sterilisation and Fees which have occurred since she learned that she was Two other issues complicate that of termination. pregnant-any more than any other depressed patient The first is sterilisation-which to me seems an entirely can. We must accept the risk that she will exaggerate. separate question. Occasionally one hears of gynaecologists There is, however, an opposite risk-in my opinion agreeing to terminate, but only if sterilisation is also far commoner-that the patient will minimise her recommended. Put like that, it sounds horribly like a symptoms because she believes that termination is likely. penalty, or possibly a bargain, and one made under Of course, no-one should have led her to think so; but duress. Sterilisation should not be considered until the sometimes someone has, perhaps unwittingly. woman is mentally able to consider the operation and its In practice, there are two main questions: will the consequences cold-bloodedly. Even if this delay somepatient’s health break down irretrievably, or will she times means a second operation, it is better to wait. commit suicide, if pregnancy goes on ? The psychiatrist The second issue is that of fees. Many patients have is thus faced with a choice, in the extremes, of risking her the impression that they can get an abortion if they pay suicide, and with it, the break-up of the family’s happiness enough-from a gynaecologist who will ask few questions, and health, of or recommending a colleague to commit advised by a psychiatrist who will ask rather more, but what some feel, and call, murder. It is indeed a harrowing in such a way as to suggest the " right " answers. decision, and I for one could well do without it. Whether it is true or not, the fact is that some patients How does he judge? Clearly not from her statement seem to believe it does much harm to our profession. alone, or she would only have to threaten suicide to get Further Evidence an abortion forthwith. It is not easy to judge how likely From it clear that the psychiatrist’s decision is this is any depressed person is to kill herself; harder if one has a difficult one. If he is to forecast her future in a connever seen the patient before; and border still if no records from anyone else are available. Some say that tinuing pregnancy, he must consider the woman’s present mental state, any changes in mood and behaviour since pregnant women do not commit suicide; but this is untrue. A factor which must influence the possibility of suicide she has known she was pregnant, her past history, and the stresses she will meet. For this he badly needs must be the amount of help to be had if pregnancy evidence from others, and objective evidence at that. The continues-from the family, from the general practitioner, and from psychiatric services. Some pregnancies are patient’s family doctor is the obvious person, for he will know her previous reaction to stress, her behaviour when terminated because no such help can be got. Yet what is well, her personality, and also how much help he can to be done ? As everyone knows, the psychiatric services give her. are stretched to the limit, and have long waiting-lists, Yet some cases come to psychiatrists without their even for support, even in London. own doctor’s knowledge. Instead of going to see him, Clearly our assessment of the patient’s ability to stand women go to another doctor whom they have not many stress must include an assessment of the stress to be met. met before. This is damaging to the status of general In Sweden, social stress is legally a sufficient ground. practice: and it seems unprofessional that she should be Here we must state that it will damage the patient’s seen by the second, except in emergency or very special health; which comes to much the same thing. circumstances. Naturally, we cannot question her right But there is another side. The risk of suicide must be to change doctors; but to go to a different doctor only weighed against the risk (often forgotten) that termination because she is pregnant is another matter. may make the woman worse mentally. One may replace That a patient should have to go to a psychiatrist or the foetus by a load of guilt, which is more difficult to treat. at a distance, simply because the local Another threat which is made is that of " going round gynxcologist known is never to touch such cases, seems even the corner " to an ’’legal abortionist. Since the physical specialist more disastrous. It is serious in its effect on relations dangers of this are great, some feel that the risk is good between patient, general practitioner, and consultant; it reason for recommending therapeutic abortion in hospital. the psychiatrist of essential information; and deprives But, even if the psychiatrist were to judge that the it casts a load on those who do not have disproportionate woman was serious in her intention, such a recommenthis reputation, and are known to try to judge each case dation would not be within the Law unless he knew how on its merits-which after all, standard medical dangerous the unprofessional (i.e., non-medical) custom. It thus causesis, ill-feeling between specialists, abortionist would really be. Goodhart (1964) writes: and penalises patients, simply because of where they It is widely believed that there may be between 5000 and to live, yet it seems to happen more and more 100,000 illegally procured abortions in Great Britain every happen we must therefore ask why. and often, year, and that the women who resort to ’back-street’ abortionOne is that the doctor’s religious views prevent reason and health. considerable to life ists are running risks his considering termination of pregnancy. If so, he must " However, the number of deaths attributed to procured not act against his conscience. But I think that if he does on Confidential abortion in the Ministry of Health’s ’Reports "
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believe this, he has also a duty to state that in no circumstances will he perform or recommend abortion, and to make it clear that this decision is based on religious grounds, not medical. The second reason is that the doctor is in doubt about the state of the Law. In view of Dr. Glanville Williams’ opinion, which I quoted earlier, I cannot agree with Sim (1963) and others in a recent British Medical Journal correspondence that there are no legal grounds for termination. The Law-as laid down in the two cases cited-is that psychiatric grounds do exist, and that they consist of a bona-fide opinion on the part of the doctor concerned. As long, therefore, as we hold that opinion, we are acting legally in recommending termination, whatever opinion some other doctor may hold (on some other case). It is judges who determine the law here, not doctors: and (it appears) they are more likely to follow Mr. Justice MacNaghten in the Bourne case rather than correspondents in a medical journal. Dr. Sim says that " a doctor who on psychiatric grounds advises and performs an abortion which is followed by undesirable mental or even physical sequelae could be sued in a civil case for negligence ". It would take a lawyer to assess the likelihood of this. The commonsense view to me is that his risk is at least no higher than that of the doctor who refrained from advising or performing abortion in a patient who later committed suicide. Dr. Sim thinks that the evidence he has produced means that it would be very hard to defend the abortion on the ground that the mother’s health was endangered. But even if his evidence had been generally acceptedwhich it was not-it would still be possible for doctors to disagree in good faith on a given case: and it is their recommendation in good faith which makes the affair legal. A third reason why doctors in various branches of medicine do not recommend or perform abortion is that they find it repugnant. With this I can well sympathise. The task of deciding is indeed a very harrowing one. Is it fair that those who are prepared to judge each case on its merits should bear the burden of those who avoid their responsibilities by saying that they will never see such cases ? Fourthly, some honestly believe abortion is bad medical practice. Is this true ? I can only answer from my own
personal experience. The Results of Termination
I work in a department which has close links with the professor of obstetrics and the consultant gynaecologists of the hospital: and the policy of the gynxcologists is not to terminate pregnancy on psychiatric grounds unless they are backed by the opinions of a consultant psychiatrist: if so backed, they are likely to act, but are of course bound to do so. On average we recommend termination in just over half the cases referred to us. All these are followed up by psychiatric social workers or psychiatrists or both. We try, too, to follow up the cases for whom we don’t recommend termination : clearly we miss a proportion, for some undoubtedly leave us in disgust. Hence our figures are not yet comparable to Hook’s study of 294 cases in Sweden. But we have found people in some of the same categories as he did: some deteriorate enough to be terminated later: some procure, or try to procure an illegal operation. I must also add here that in some cases psychiatric help has not only brought the woman to accept the pregnancy, and to accept the child, but has even resolved the conflicts not
between husband and wife that made the pregnancy unwanted. I say this partly to emphasise the need to try to seize the opportunity of the unwanted pregnancy to achieve this end: and partly to show that we do try to judge each on case its merits. We certainly do not regard termination as the easy way out, to be taken when in doubt. I must also add that it is exceedingly rare for termination to be followed by acute depression: though there have been minor reactions, the only severe one was years ago. Perhaps the psychiatric support given before and after the operation helps to prevent this depression, or perhaps our predictions are better. But in the vast majority of cases terminated, the woman afterwards seems well, cooperative and grateful. I agree we need more figures here, from many different centres. In the meanwhile we have no option but to go on doing, here as in other spheres of medicine, the best we can for our patients in the light of our experience, of what other knowledge is available, of our common sense, and of our judgment on each case. At present I have no doubt that termination is the right course for many. The Remedies: Legal and Medical If the situation is as deplorable as I have suggested, what are the remedies ? Some are legal, some medical. 1. Reforms in the Law have been proposed, and I agree that some would be beneficial. But I myself think that the Law needs not so much changing as publicising. The trouble is that people do not know what it does say, or do not trust its interpreters. Both points would be met if a statute law was made. Besides this, I would favour certain minor changes: I
would include certain conditions-e.g., rape-as grounds for termination: provided, of course, the doctor was satisfied that rape had occurred. At present rape is accepted in Sweden: but not here, and we cannot recommend abortion unless continuation of pregnancy due to rape would damage the mother’s health. Secondly it is not clear whether termination can legally be undertaken on the grounds that continuation of the pregnancy would damage the health, not of the mother, but of the foetus or of the father or grandmother (both have been recorded). This should be clarified. Discussion here has often led to another question: should any mother be compelled to go on carrying a child she does not want ? Is it really civilised to make her do so ? The suggestion that she should have the last word is likely of course to raise eyebrows, if not blood-pressures; and so far our society has come nowhere near this. But then our society has been run by men for centuries: women only got the vote within living memory: and this question is not one we can argue dispassionately yet. I would suggest that a body of professional people, general practitioners, psychiatrists, gynaecologists, and social workers should tackle the subject; but they must all have one qualification as well as their professional one-they must be women of childbearing age. If the mother had the last word, naturally the doctor would still have the duty of discussing the problem with the would-be aborter and stating pros and cons. I believe this has been the situation in the U.S.S.R.
But legal changes are, to me, less important than setting house in order. What can be suggested for medical reforms ? 2. All patients should be seen by their family doctor first. This would be the rule-though I can visualise a our own
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THE PROXIMAL CONVOLUTED TUBULE exception-e.g., if the doctor were also the husband of the woman, or her father (neither of which is desirable IN THE RENAL HANDLING OF WATER anyhow). The general practitioner must be prepared to E. M. DARMADY get it across to all his patients that whatever he is told is M.D. Cantab., F.R.C.P., F.C.Path. He confidential. of do course so should entirely anyhow, and most of us think he does, but not all patients think so. J. OFFER B.Sc. Lond. 3. If the family doctor feels that, because of his religious views, he cannot consider abortion ever permissible, then FAY STRANACK JUNE PRINCE he should say so to the patient. But if the patient’s A.I.M.L.T. Ph.D. Lond. views are and she an still wants different, religious opinion From the Portsmouth and Isle of Wight Area Pathological Service on medical (not religious) grounds then it seems to me the IT is usually accepted that about seven-eighths of the onus is on her general practitioner to give another practiwater of the glomerular filtrate is reabsorbed obligatorily tioner all the medical information and ask him to advise her. This, however, should be openly arranged. Let me make in the proximal convoluted tubule, while the remaining it plain here that I am not trying to impose my religious one-eighth is reabsorbed facultatively in the distal and views on those who honestly hold different ones: nor am collecting tubules under the control of antidiuretic I trying to persecute them: all I ask is that they should not hormone. In previous communications (Clay, Darmady, and impose theirs on their patients who go to them for professional advice, not religious. Here, as elsewhere, the Hawkins 1953, Darmady and Stranack 1954) we have doctor should not usurp the priest’s functions. pointed out that in nephrogenic diabetes insipidus and 4. No other general practitioner should see any patient cystinosis (Fanconi syndrome) the proximal convoluted . tubule appeared to be shorter than normal. It occurred to without the knowledge of her own general practitionerus that the inadequate reabsorption of solute and water in or if he does so inadvertently he should at once get into these two diseases might account for the inability of the touch with the latter. This is not only for reasons of professional etiquette: it is more because her own doctor’s kidney to respond to antidiuretic hormone, since more water and solute reach the lower nephron than the account is vital in assessing the case. reabsorptive mechanism can manage. 5. The same should surely apply to specialists. I supIn 3 cases of nephrogenic diabetes insipidus and 13 cases pose that in most parts of the country a general practitioner consults one gynxcologist, and one psychiatrist for all he of cystinosis the lengths of the proximal convoluted needs in their respective specialties. This seems excellent tubules have been compared with similar measurements to me, and good team-work. In other places, such as from 31 children of comparable age with normal kidneys, London, the practitioner has a wider choice, and feels he and from 4 cases of nephrotic syndrome. does better for his patients by choosing one psychiatrist Material and Methods for some patients and another for others. This is reasonPortions of renal tissue fixed in 10%neutral formol-saline able. It seems, however, most undesirable if he gets to the were selected from representative areas. They were macerated or a stage of using a psychiatrist only to advise on for forty-eight hours in concentrated hydrochloric acid as to do them: and I the think gynaecologist only practitioner described by can hardly blame the specialist who refuses to be used in Darmady and rare
abortions,
this way.
6. In no circumstances should fees be charged for advice or operation. The evils that arise from fees have already been discussed.
Consequences If these remedies were applied, several consequences would follow. We should avoid much abuse of the profession, and the fear of it. Each general practitioner, psychiatrist, and gynaecologist would be forced to see and accept responsibility for his own cases, which after all is still his job, even if they do have an unwanted pregnancy. And we should have an opportunity of estimating the size of the problem, in the country. At present, we cannot do so; for now anyone who does not like terminations ceases to see patients who require them, and soon comes to believe that none exist. If I let it be widely known that obsessionats, for example, were contemptible people, and their symptoms the results of their own folly, I should not be sent many: after a time I should believe no-one else saw them either, and then of course it would be logical for me to condemn a colleague who reported a few, and was actually trying to help them, as a misguided timewaster. REFERENCES C. B.
Goodhart, (1964) Eugen. Rev. 55, 197. Hook, K. (1963) Acta psychiat. scand. 39, suppl. 168. Sim, M. (1963) Brit. med. J. ii, 681. Williams, Glanville. (1958) The Sanctity of Life and chaps. v and VI. London.
the Criminal Law;
Stranack In order to en-
(1957).
complete reproducibility, macerasure
t i o n carried a
was s
out
in
constant-
temperature cabinet at 18°C. The
proximal
con-
voluted tubules were dissected with micromani-
pulators, and measurements to the nearest
Fig. 1-Three
zones
of
a
bisected kidney.
0.1 mm. were made within forty-eight hours of maceration, by means of a micrometer eyepiece. The lapse of.time between maceration and measurement had to be standardised. We found that the measured length of tubules varied by as much as 0-2 mm. over six to twenty-four hours. The cause of this change has been discussed by Osathanondh and Potter (1963). The differences in length of the proximal convoluted tubules in different areas of the kidney were studied in three normal kidneys from children aged 3, 6, and 10. The bisected kidney was divided into three main zones, which we’have termed polar, temperate and equatorial (fig. 1). 50 proximal
SOME psychiatrists and gynaecologists feel that pregnancy should never be terminated on psychiatric grounds. Other psychiatrists, on the other hand, are prepared to recommend abortion in a majority of the cases they see,
and many gynaecologists are prepared to act at once on their recommendation. Similar differences are seen in the views of general practitioners, patients, and the public (who, of course, include patients’ relatives). Wide ranges of opinion are not unusual among doctors, and in general are healthy enough: they lead to arguments which, though they may be heated, seldom last long, and often allow the development of a body of opinion which discards the exaggerations of both sides. On some subjects, however, disagreement is more violent and lasts longer, often leading the protagonists to attack not only the opinions but also the integrity of their opponents. This is more characteristic of political or religious than of scientific controversy; and we know, of course, that abortion raises ethical and religious problems. three questions are much debated. First, has the foetus a soul ? Secondly, if it has, what happens to this soul if the foetus dies unbaptised ? and, thirdly, when does the foetus become a " person " and at what stage does termination become murder ? To this last question the most general reply seems to be, at quickening. This occurs at different times in different pregnancies but has the advantages of being recognisable by the mother, and of corresponding, roughly, with the recognition of the fcetus as a human being by the theatre staff. Until recently pregnancies were terminated before quickening; but, now that some gynaecologists prefer to operate at sixteen weeks, the emotional strain on the theatre staff will be greater. It is already severe, since gynxcologists and nurses involved in termination are asked to destroy life rather than to save it, as they have been trained to do. Indeed, we can sympathise with the gynaecologist who said that if psychiatrists recommend abortion they should learn to do it themselves (though this I would oppose on many grounds). We can have even more sympathy for nurses, who can scarcely refuse to do what they are told by gynaecologists and often cannot voice their reluctance. The State of the Law
Apart from these uncertainties, many people are not clear about the state of the Law in this country-still less about its state elsewhere. It is widely believed, for instance, that termination is much easier to get in Sweden; this is by no means true, for the Swedish criteria, though different from ours, are stringent. Many mothers or would-not-be-mothers have taken a plane to * Maudsley Bequest lecture given at the Royal Society of Medicine, on Feb 11, 1964. 7372
I2
December I964
Stockholm, with or without their doctor’s recommendation, to return still pregnant. It is not easy for a doctor to be sure of the Law; and I recommend those who wish to follow the legal arguments in detail to read the writings of Dr. Glanville Williams (1958). Briefly he holds that the findings of two wellknown cases, Rex v. Bourne, and Rex v. Bergman and Ferguson, have provided enough precedent to establish that if the doctor terminates, or recommends termination in good faith, to save the mother’s life, or prevent serious injury to her health-the phrase is " to prevent her becoming a physical or mental wreck "-he is within the law. Dr. Williams says: Some doctors are afraid that the decision in the Bourne case will be reversed in some future case in which they themselves are prosecuted. It may be safely said that this fear is unfounded. It is true, some other judge might refuse to follow the direction in Rex v. Bourne, and his decision might be upheld by the court of Criminal Appeal. Every lawyer knows this is
only
"
not a
practical possibility."
To me this seems clear enough, but not everyone has read it. The difficulty, of course, lies in deciding whether or no the woman’s life or health is in danger; and this is partly because of the way in which she presents herself to the doctor. The Scene at Consultation The different types of patient, and the way they come, were well described by a psychiatrist in the Observer for
Nov. 24, 1963: are remarkably varied. The woman unmarried, or the mother of a large family at the end of her tether; she may have been the victim of rape, or seduction under drugs; she may have had a series of sexual affairs with little forethought or self-control, or be a young wife taking every contraceptive precaution to postpone pregnancy. She may have been in contact with an infection, or a drug,
" The circumstances
may be young and
that makes her believe her child will be a monster, or she may that this is so; she may have religious views against abortion, or glory in free-love, even if she deplores its consequences as’unfair to women’; she may be a career woman, or be mentally subnormal; she may be entirely without help, or supported by a loving family.... She may be depressed; angry with the father, with herself, and anyone else who won’t do what she wants; anxious, pathetic, courageous or defiant. She may consciously exaggerate her symptoms."
pretend
These situations will certainly arouse different reactions in the minds of those who hear the story-relative, nurse, general practitioner, gynaecologist, even psychiatrist. One may feel entirely sympathetic with the victim of rape, or with the mother of seven who realises that her eighth child is likely to be a thalidomide baby; one may feel irritated by an admittedly casual amateur who has taken no precautions; or one may feel counter-aggressive to a defiant girl whose anger (with herself) is vented on all Of course, the psychiatrist is helped by his comers. to understand, and at least allow for, his own training natural reactions; but perhaps he is not always as successful in doing so as he thinks. And it is wise to
1252
remember Becket’s temptation in T. S. Eliot’s masterpiece : to refrain from doing the right thing, simply because there is a wrong reason for doing it-and because it might seem (to others) that this was why it was done. Collection of Evidence
Enquiries into Maternal Deaths in England and Wales’ shows that, if illegal abortion is as common as it is supposed to be, the risks to life involved cannot be much more than in normal childbirth, in which the maternal mortality rate is now regarded as very satisfactorily low. " It would seem therefore either that the professional competence of criminal abortionists has been very seriously underrated, or else, and surely more probable, that their numbers have been much exaggerated."
There are other difficulties. The situation is one of the few in medicine when the patient may have an interest in deceiving the doctor; and doctors do not like that, which is a further emotional complication. But even the I am not sure that I share Dr. Goodhart’s opinion as to entirely honest patient may not be able to give a very which is the more probable of these two. objective account of the changes in her mental state Sterilisation and Fees which have occurred since she learned that she was Two other issues complicate that of termination. pregnant-any more than any other depressed patient The first is sterilisation-which to me seems an entirely can. We must accept the risk that she will exaggerate. separate question. Occasionally one hears of gynaecologists There is, however, an opposite risk-in my opinion agreeing to terminate, but only if sterilisation is also far commoner-that the patient will minimise her recommended. Put like that, it sounds horribly like a symptoms because she believes that termination is likely. penalty, or possibly a bargain, and one made under Of course, no-one should have led her to think so; but duress. Sterilisation should not be considered until the sometimes someone has, perhaps unwittingly. woman is mentally able to consider the operation and its In practice, there are two main questions: will the consequences cold-bloodedly. Even if this delay somepatient’s health break down irretrievably, or will she times means a second operation, it is better to wait. commit suicide, if pregnancy goes on ? The psychiatrist The second issue is that of fees. Many patients have is thus faced with a choice, in the extremes, of risking her the impression that they can get an abortion if they pay suicide, and with it, the break-up of the family’s happiness enough-from a gynaecologist who will ask few questions, and health, of or recommending a colleague to commit advised by a psychiatrist who will ask rather more, but what some feel, and call, murder. It is indeed a harrowing in such a way as to suggest the " right " answers. decision, and I for one could well do without it. Whether it is true or not, the fact is that some patients How does he judge? Clearly not from her statement seem to believe it does much harm to our profession. alone, or she would only have to threaten suicide to get Further Evidence an abortion forthwith. It is not easy to judge how likely From it clear that the psychiatrist’s decision is this is any depressed person is to kill herself; harder if one has a difficult one. If he is to forecast her future in a connever seen the patient before; and border still if no records from anyone else are available. Some say that tinuing pregnancy, he must consider the woman’s present mental state, any changes in mood and behaviour since pregnant women do not commit suicide; but this is untrue. A factor which must influence the possibility of suicide she has known she was pregnant, her past history, and the stresses she will meet. For this he badly needs must be the amount of help to be had if pregnancy evidence from others, and objective evidence at that. The continues-from the family, from the general practitioner, and from psychiatric services. Some pregnancies are patient’s family doctor is the obvious person, for he will know her previous reaction to stress, her behaviour when terminated because no such help can be got. Yet what is well, her personality, and also how much help he can to be done ? As everyone knows, the psychiatric services give her. are stretched to the limit, and have long waiting-lists, Yet some cases come to psychiatrists without their even for support, even in London. own doctor’s knowledge. Instead of going to see him, Clearly our assessment of the patient’s ability to stand women go to another doctor whom they have not many stress must include an assessment of the stress to be met. met before. This is damaging to the status of general In Sweden, social stress is legally a sufficient ground. practice: and it seems unprofessional that she should be Here we must state that it will damage the patient’s seen by the second, except in emergency or very special health; which comes to much the same thing. circumstances. Naturally, we cannot question her right But there is another side. The risk of suicide must be to change doctors; but to go to a different doctor only weighed against the risk (often forgotten) that termination because she is pregnant is another matter. may make the woman worse mentally. One may replace That a patient should have to go to a psychiatrist or the foetus by a load of guilt, which is more difficult to treat. at a distance, simply because the local Another threat which is made is that of " going round gynxcologist known is never to touch such cases, seems even the corner " to an ’’legal abortionist. Since the physical specialist more disastrous. It is serious in its effect on relations dangers of this are great, some feel that the risk is good between patient, general practitioner, and consultant; it reason for recommending therapeutic abortion in hospital. the psychiatrist of essential information; and deprives But, even if the psychiatrist were to judge that the it casts a load on those who do not have disproportionate woman was serious in her intention, such a recommenthis reputation, and are known to try to judge each case dation would not be within the Law unless he knew how on its merits-which after all, standard medical dangerous the unprofessional (i.e., non-medical) custom. It thus causesis, ill-feeling between specialists, abortionist would really be. Goodhart (1964) writes: and penalises patients, simply because of where they It is widely believed that there may be between 5000 and to live, yet it seems to happen more and more 100,000 illegally procured abortions in Great Britain every happen we must therefore ask why. and often, year, and that the women who resort to ’back-street’ abortionOne is that the doctor’s religious views prevent reason and health. considerable to life ists are running risks his considering termination of pregnancy. If so, he must " However, the number of deaths attributed to procured not act against his conscience. But I think that if he does on Confidential abortion in the Ministry of Health’s ’Reports "
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believe this, he has also a duty to state that in no circumstances will he perform or recommend abortion, and to make it clear that this decision is based on religious grounds, not medical. The second reason is that the doctor is in doubt about the state of the Law. In view of Dr. Glanville Williams’ opinion, which I quoted earlier, I cannot agree with Sim (1963) and others in a recent British Medical Journal correspondence that there are no legal grounds for termination. The Law-as laid down in the two cases cited-is that psychiatric grounds do exist, and that they consist of a bona-fide opinion on the part of the doctor concerned. As long, therefore, as we hold that opinion, we are acting legally in recommending termination, whatever opinion some other doctor may hold (on some other case). It is judges who determine the law here, not doctors: and (it appears) they are more likely to follow Mr. Justice MacNaghten in the Bourne case rather than correspondents in a medical journal. Dr. Sim says that " a doctor who on psychiatric grounds advises and performs an abortion which is followed by undesirable mental or even physical sequelae could be sued in a civil case for negligence ". It would take a lawyer to assess the likelihood of this. The commonsense view to me is that his risk is at least no higher than that of the doctor who refrained from advising or performing abortion in a patient who later committed suicide. Dr. Sim thinks that the evidence he has produced means that it would be very hard to defend the abortion on the ground that the mother’s health was endangered. But even if his evidence had been generally acceptedwhich it was not-it would still be possible for doctors to disagree in good faith on a given case: and it is their recommendation in good faith which makes the affair legal. A third reason why doctors in various branches of medicine do not recommend or perform abortion is that they find it repugnant. With this I can well sympathise. The task of deciding is indeed a very harrowing one. Is it fair that those who are prepared to judge each case on its merits should bear the burden of those who avoid their responsibilities by saying that they will never see such cases ? Fourthly, some honestly believe abortion is bad medical practice. Is this true ? I can only answer from my own
personal experience. The Results of Termination
I work in a department which has close links with the professor of obstetrics and the consultant gynaecologists of the hospital: and the policy of the gynxcologists is not to terminate pregnancy on psychiatric grounds unless they are backed by the opinions of a consultant psychiatrist: if so backed, they are likely to act, but are of course bound to do so. On average we recommend termination in just over half the cases referred to us. All these are followed up by psychiatric social workers or psychiatrists or both. We try, too, to follow up the cases for whom we don’t recommend termination : clearly we miss a proportion, for some undoubtedly leave us in disgust. Hence our figures are not yet comparable to Hook’s study of 294 cases in Sweden. But we have found people in some of the same categories as he did: some deteriorate enough to be terminated later: some procure, or try to procure an illegal operation. I must also add here that in some cases psychiatric help has not only brought the woman to accept the pregnancy, and to accept the child, but has even resolved the conflicts not
between husband and wife that made the pregnancy unwanted. I say this partly to emphasise the need to try to seize the opportunity of the unwanted pregnancy to achieve this end: and partly to show that we do try to judge each on case its merits. We certainly do not regard termination as the easy way out, to be taken when in doubt. I must also add that it is exceedingly rare for termination to be followed by acute depression: though there have been minor reactions, the only severe one was years ago. Perhaps the psychiatric support given before and after the operation helps to prevent this depression, or perhaps our predictions are better. But in the vast majority of cases terminated, the woman afterwards seems well, cooperative and grateful. I agree we need more figures here, from many different centres. In the meanwhile we have no option but to go on doing, here as in other spheres of medicine, the best we can for our patients in the light of our experience, of what other knowledge is available, of our common sense, and of our judgment on each case. At present I have no doubt that termination is the right course for many. The Remedies: Legal and Medical If the situation is as deplorable as I have suggested, what are the remedies ? Some are legal, some medical. 1. Reforms in the Law have been proposed, and I agree that some would be beneficial. But I myself think that the Law needs not so much changing as publicising. The trouble is that people do not know what it does say, or do not trust its interpreters. Both points would be met if a statute law was made. Besides this, I would favour certain minor changes: I
would include certain conditions-e.g., rape-as grounds for termination: provided, of course, the doctor was satisfied that rape had occurred. At present rape is accepted in Sweden: but not here, and we cannot recommend abortion unless continuation of pregnancy due to rape would damage the mother’s health. Secondly it is not clear whether termination can legally be undertaken on the grounds that continuation of the pregnancy would damage the health, not of the mother, but of the foetus or of the father or grandmother (both have been recorded). This should be clarified. Discussion here has often led to another question: should any mother be compelled to go on carrying a child she does not want ? Is it really civilised to make her do so ? The suggestion that she should have the last word is likely of course to raise eyebrows, if not blood-pressures; and so far our society has come nowhere near this. But then our society has been run by men for centuries: women only got the vote within living memory: and this question is not one we can argue dispassionately yet. I would suggest that a body of professional people, general practitioners, psychiatrists, gynaecologists, and social workers should tackle the subject; but they must all have one qualification as well as their professional one-they must be women of childbearing age. If the mother had the last word, naturally the doctor would still have the duty of discussing the problem with the would-be aborter and stating pros and cons. I believe this has been the situation in the U.S.S.R.
But legal changes are, to me, less important than setting house in order. What can be suggested for medical reforms ? 2. All patients should be seen by their family doctor first. This would be the rule-though I can visualise a our own
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THE PROXIMAL CONVOLUTED TUBULE exception-e.g., if the doctor were also the husband of the woman, or her father (neither of which is desirable IN THE RENAL HANDLING OF WATER anyhow). The general practitioner must be prepared to E. M. DARMADY get it across to all his patients that whatever he is told is M.D. Cantab., F.R.C.P., F.C.Path. He confidential. of do course so should entirely anyhow, and most of us think he does, but not all patients think so. J. OFFER B.Sc. Lond. 3. If the family doctor feels that, because of his religious views, he cannot consider abortion ever permissible, then FAY STRANACK JUNE PRINCE he should say so to the patient. But if the patient’s A.I.M.L.T. Ph.D. Lond. views are and she an still wants different, religious opinion From the Portsmouth and Isle of Wight Area Pathological Service on medical (not religious) grounds then it seems to me the IT is usually accepted that about seven-eighths of the onus is on her general practitioner to give another practiwater of the glomerular filtrate is reabsorbed obligatorily tioner all the medical information and ask him to advise her. This, however, should be openly arranged. Let me make in the proximal convoluted tubule, while the remaining it plain here that I am not trying to impose my religious one-eighth is reabsorbed facultatively in the distal and views on those who honestly hold different ones: nor am collecting tubules under the control of antidiuretic I trying to persecute them: all I ask is that they should not hormone. In previous communications (Clay, Darmady, and impose theirs on their patients who go to them for professional advice, not religious. Here, as elsewhere, the Hawkins 1953, Darmady and Stranack 1954) we have doctor should not usurp the priest’s functions. pointed out that in nephrogenic diabetes insipidus and 4. No other general practitioner should see any patient cystinosis (Fanconi syndrome) the proximal convoluted . tubule appeared to be shorter than normal. It occurred to without the knowledge of her own general practitionerus that the inadequate reabsorption of solute and water in or if he does so inadvertently he should at once get into these two diseases might account for the inability of the touch with the latter. This is not only for reasons of professional etiquette: it is more because her own doctor’s kidney to respond to antidiuretic hormone, since more water and solute reach the lower nephron than the account is vital in assessing the case. reabsorptive mechanism can manage. 5. The same should surely apply to specialists. I supIn 3 cases of nephrogenic diabetes insipidus and 13 cases pose that in most parts of the country a general practitioner consults one gynxcologist, and one psychiatrist for all he of cystinosis the lengths of the proximal convoluted needs in their respective specialties. This seems excellent tubules have been compared with similar measurements to me, and good team-work. In other places, such as from 31 children of comparable age with normal kidneys, London, the practitioner has a wider choice, and feels he and from 4 cases of nephrotic syndrome. does better for his patients by choosing one psychiatrist Material and Methods for some patients and another for others. This is reasonPortions of renal tissue fixed in 10%neutral formol-saline able. It seems, however, most undesirable if he gets to the were selected from representative areas. They were macerated or a stage of using a psychiatrist only to advise on for forty-eight hours in concentrated hydrochloric acid as to do them: and I the think gynaecologist only practitioner described by can hardly blame the specialist who refuses to be used in Darmady and rare
abortions,
this way.
6. In no circumstances should fees be charged for advice or operation. The evils that arise from fees have already been discussed.
Consequences If these remedies were applied, several consequences would follow. We should avoid much abuse of the profession, and the fear of it. Each general practitioner, psychiatrist, and gynaecologist would be forced to see and accept responsibility for his own cases, which after all is still his job, even if they do have an unwanted pregnancy. And we should have an opportunity of estimating the size of the problem, in the country. At present, we cannot do so; for now anyone who does not like terminations ceases to see patients who require them, and soon comes to believe that none exist. If I let it be widely known that obsessionats, for example, were contemptible people, and their symptoms the results of their own folly, I should not be sent many: after a time I should believe no-one else saw them either, and then of course it would be logical for me to condemn a colleague who reported a few, and was actually trying to help them, as a misguided timewaster. REFERENCES C. B.
Goodhart, (1964) Eugen. Rev. 55, 197. Hook, K. (1963) Acta psychiat. scand. 39, suppl. 168. Sim, M. (1963) Brit. med. J. ii, 681. Williams, Glanville. (1958) The Sanctity of Life and chaps. v and VI. London.
the Criminal Law;
Stranack In order to en-
(1957).
complete reproducibility, macerasure
t i o n carried a
was s
out
in
constant-
temperature cabinet at 18°C. The
proximal
con-
voluted tubules were dissected with micromani-
pulators, and measurements to the nearest
Fig. 1-Three
zones
of
a
bisected kidney.
0.1 mm. were made within forty-eight hours of maceration, by means of a micrometer eyepiece. The lapse of.time between maceration and measurement had to be standardised. We found that the measured length of tubules varied by as much as 0-2 mm. over six to twenty-four hours. The cause of this change has been discussed by Osathanondh and Potter (1963). The differences in length of the proximal convoluted tubules in different areas of the kidney were studied in three normal kidneys from children aged 3, 6, and 10. The bisected kidney was divided into three main zones, which we’have termed polar, temperate and equatorial (fig. 1). 50 proximal