On Abortion in the Context of Malta: a Medical Doctor’s Perspective

It is extremely important to differentiate between being anti-abortion at an individual level and being anti-legalising-abortion (anti-choice), a distinction that is often overlooked. It is perfectly reasonable and respectable for individuals who would never have an abortion themselves to be pro-choice.

by Gilbert Gravino

Illustrations by the author

 

[dropcap]A[/dropcap]t the heart of every debate on abortion are its scientific, moral, social, psychological and medical aspects. They all play a crucial role in formulating an opinion and taking a stance on the issue.

 

On the Scientific Aspect of Abortion

Pregnancy is indeed a process. It starts with a man’s sperm fertilising a woman’s egg which forms a single-celled zygote, and then progresses through a sequence of stages to become a more complex embryo and then a foetus. These stages heavily rely on being nourished and supported by the woman, particularly in the early stages of a pregnancy. Eventually, if delivered successfully, this becomes an independent, biologically self-sustained body.

It is fair to say that the genetic composition of the cell in a fertilised-egg-stage is identical to the genetic composition of each cell in the adult-independent-human-stage. However, this does not mean that the entity as a whole remains unchanged along the entire spectrum of the process. Having the same genetic composition within each cell is not sufficient to regard these different stages as scientifically the same or equal—the anatomy is different, the physiology is different, the senses are different and the conscious state is different.

For example, we know that the brain cortex and the thalamo-cortical complex, which are crucial for human consciousness, are not intact before 24 weeks of gestation. Before this time, the developing foetus is incapable of any form of conscious awareness and unable to experience pain in any sense. Even then, the foetus remains in a continuous sleep-like state and unconscious partially due to in utero sedation and nerve inhibition (a result of the womb environment and chemicals secreted by the placenta). Such issues have a bearing on people’s opinion regarding up to which point abortion should be done, if at all. (Note: Over 90% of legally-induced abortions in U.K. and U.S. happen at ≤ 13 weeks gestation*. Foetal anomalies that are not detected before this gestational age contribute to later stage abortions.)

 

 

Many are opposed to abortion because they recognise the entity in utero as a living entity. However, we need to appreciate that there are different forms of life (as the entity in utero changes along the process) and a ‘killing’ needs to be put into the context of what sort of life is actually being terminated. For that matter, a sperm is also effectively a living entity that carries potential to form a mature human being. Therefore, a more important question to ask is whether the entity in utero constitutes a person or not. This remains ambiguous territory and there is no scientific answer to this question.

We must not pretend that this is a black and white issue. The divergent views on this conundrum completely rely on very personal moral beliefs which are in turn influenced by societal norms. This brings me to my next point…

 

On the Moral Aspect of Abortion

People consider abortion as morally right or wrong primarily on the basis of the value they attribute to the entity in utero and whether they regard this as a person or not. Importantly, this is completely based on the individual’s personal reasoning or moral beliefs developed in the context of social values and predominant attitudes. For this reason, arguing that all the major political parties and the majority of people in Malta have a certain set of moral beliefs against abortion, and we should therefore not discuss this agenda, is a very unfair argument.

There is no place for self-perceived moral superiority in a healthy society. It is quite arrogant, intolerant and undesirable for humanity at large for anyone to say that their moral values are definitely right and those of others are definitely wrong or that established values are necessarily right. This is because there is no indisputable reliable measure to determine who of us is right or wrong about what is morally right (‘good’) or morally wrong (‘bad’).

 

 

Nonetheless, we aim for a society where we can all live together harmoniously and try to minimise any cause of social stress. This necessitates tolerance and respect for others’ moral values, and it is what being pro-choice is ultimately about.

I feel obliged at this point to make it clear that medical doctors are no more equipped than anyone else to decide what is morally right or wrong. Nobody is, and this is why nobody should decide for anyone else. It remains an individual personal matter, and therefore the patient’s choice should be autonomous and respected by all doctors in every circumstance. This includes a patient’s choice to have or not to have chemotherapy for cancer, a Jehovah’s witness’ choice to have or not to have a blood transfusion… and the choice to have or not to have an abortion.

 

The pro-choice stance respects the views of all conscious beings, allowing all individuals to decide for themselves. Conversely, the anti-choice stance (opposing the legalisation of abortion) simply disregards those who have no moral objection to having it done, and in so doing it does not respect or tolerate their moral values. Therefore, it is extremely important to differentiate between being anti-abortion at an individual level and being anti-legalising-abortion (anti-choice), a distinction that is often overlooked. It is perfectly reasonable and respectable for individuals who would never have an abortion themselves to be pro-choice.

 

On the Social Aspect of Abortion

Improving social services, ameliorating help in the community, providing education and giving access to contraceptives are all very important, but unfortunately do not stop the occurrence of all unwanted or complicated pregnancies. Just consider that contraceptives are not 100% effective, the circumstance of a rape victim, the occurrence of non-viable pregnancies and a pregnancy with a threat to the woman’s health or life.

The option of travelling abroad for an abortion is not sufficient as it discriminates against those who are unable to travel. This includes those with financial difficulties, sole guardians of children/dependents, victims of domestic abuse, and migrants lacking necessary documentation. When these factors are not an issue, there is still a problem in that the process is delayed and abortion may have to be carried out at a slightly later stage.

 

 

A woman who opts for an abortion is often labelled as selfish. Many suggest that the offspring could be given for adoption so that families who cannot have children of their own can be made happy and fulfilled. I deeply empathise with couples in this situation, but forcing someone through an unwanted pregnancy and making them give birth for this purpose is not the right solution—this is what I would regard as more truly selfish.

I can almost draw parallels between this idea and the dystopian world of The Handmaid’s Tale which is dominated by the subjugation of women. Women who are fertile but do not want children are in no way indebted to those who are biologically unable to have children. The other form of ‘selfishness’, where a person wants to have control over their own moral values and control over their own body is something that we should all encourage and support if we all want to be free individuals. This form of ‘selfishness’ does not mean that we do not help and support each other. However, we all need to take care of ourselves and be allowed to make decisions that are fair and make us happy before we are capable of pleasing and actively taking care of others.

Unfortunately, the anti-choice movement and the current law in Malta create a hostile social environment for those who hold different views, but primarily for the women who want to have or have had an abortion.

It is my personal view that a woman in this situation should be respected, regarded more highly and have her say on a matter that has an impact on her well-being. Especially when I consider a premature entity in utero that is incapable of consciousness and that is biologically directly dependent on the woman’s body (affecting her health). I also think that it is not sensible to fight for an unconscious unborn to be born, only to have the freedom of exerting their own moral beliefs and freethought taken away from them (whether this affects the right to access abortion or any other moral issue).

 

 

Lack of freedom in this regard has a very negative impact on the quality of life. Forcing women to carry unwanted or complicated pregnancies to term, or stigmatising them for having an abortion, is certainly not helping anyone in society or improving the quality of life of any sentient being. Not to mention the fact that criminalised abortion results in some women risking their lives by resorting to drastic and unsafe means to terminate unwanted pregnancies.

Women are by far the most affected in the debate on abortion as they are the ones experiencing the pregnancy, all the changes it brings with it and its delivery. However, it also affects men. Men are affected directly when, for example, part of a relationship that is not ready to have children (or more children), and indirectly by living in a society where women do not feel free and autonomous. This is stressful on women, which in turn impacts on the general well-being of society as a whole. Personally, I would rather live in a community where everyone, including all the women in our lives (partners, wives, siblings, mothers, daughters, female friends, etc.) feel free and content.

 

On the Psychological and Emotional Aspect of Abortion

Women can change their minds about abortion after experiencing an uninterrupted pregnancy or induced termination. Amongst the women who have an abortion, there are those who eventually regret it and those who never come to regret it (as with any other life choice). If you hear enough stories you realise that all of these scenarios exist.

Conducting large cohort studies to assess the psychological aspect of abortion is not yet possible in Malta due to the immense stigma and hostility which stops women from coming forward and being open about their experiences. Although not generalisable, small qualitative studies and portals like ‘Break the Taboo Malta’ remain crucial in that they tell stories which so far have been largely hidden by the media. If you juxtapose these stories with what is repeatedly told by many anti-choice organisations—that all women suffer mental problems as a result of abortion—you can tell that this is a very sensationalist and unrealistic sweeping statement. Needless to say, the exposure these organisations get is skewed and also not generalisable in that they are mainly approached by women who fit their views on abortion.

 

Another issue to consider is the fact that out of those who do experience regret, many could be the result of heavy stigmatisation and hostility by society, rather than the abortion itself.

 

 

Since we cannot rely on local data presented by either the pro-choice or the anti-choice movements, we must therefore look at international data. Three large meta-analyses and critical reviews investigating the association between abortion and mental health problems are those conducted by the Academy of Medical Royal Colleges, the American Psychological Association and Charles Reviews**, all of which concluded that there is no significant association. Mental health problems correlated with abortion were not causally linked, i.e. not caused by the abortion itself but relate to substantial confounding social factors. Therefore, the false notion that abortions cause mental illness is unfounded and untrue. Studies also reflect that a common sentiment after an abortion is relief.

 

On the Medical Aspect of Abortion

In any medical condition it is always best practice to avoid medications and surgery wherever possible, as these always have side effects and risks. However, in certain circumstances where their benefit outweighs the risk, it may be sensible to use these methods. The same applies for abortion.

Ideally, the scenario of an unwanted pregnancy and the need for abortion is avoided altogether. However, unwanted and complicated pregnancies continue to happen due to the unforeseen circumstances already mentioned. In these cases, given the woman is in favour of having a termination, the benefit of an abortion could outweigh the risks. When carried out in a professionally controlled manner (as is the case in countries where it is legal) these are generally very safe (although still carrying certain risks as with any other medical procedure or surgery). Needless to say, a pregnancy also has its own risks.

 

 

The current law in Malta does not allow abortion under any circumstance, even when the woman’s life is in danger.

The principle of double effect (PDE) can be applied to counter this limitation. This ethical principle stipulates that it is permissible to do something ‘morally good’ that has a ‘morally bad’ side-effect, providing the latter was not the intention, even if it was foreseen. By applying this principle (in the context of Maltese law which considers Catholic teaching as the normative value), doctors can only save the woman when the life of the foetus is terminated indirectly. In practice this is applied, for example, in the case of an ectopic pregnancy. This refers to an embryo that is growing outside the womb, usually in one of the fallopian tubes where it cannot survive. Through the PDE, the condition can be treated by surgically removing the tube containing the embryo.

With that said, illegalised abortion still limits the quality of care. Consider a woman who becomes pregnant and has a heart defect or other disease that is known to pose a great risk to her life. She would like to terminate early not to take any risks, but cannot do so as it is illegal. Doctors will try to save both the woman and the foetus by waiting for the latter to reach a stage where it can thrive outside the womb and get it delivered. In the meantime, the woman has to undergo the physiological and physical effects of the pregnancy and the delivery, which could severely compromise her health and her life. These effects can persist even after the baby has been delivered.

Consider then a pregnancy involving a non-viable foetus such as in the case of anencephaly. As the current law stands, a woman in Malta in this situation has to carry the pregnancy and deliver a stillborn, or deliver a baby that dies hours or days after being born. A pro-choice position allows women to choose, and if they would rather continue with the pregnancy they can opt for this. It also gives the option of terminating the pregnancy for those who feel that it poses a great deal of emotional anguish and practical difficulties.

 

 

Some argue that we should always let nature take its course and not play god. This view is quite flawed and ironic, as it contradicts the current medical practice which is widely accepted by doctors and patients. In medicine, we constantly manipulate natural occurrences to try and improve our well-being and quality of life. This varies from relatively simple therapy like treating an infection with antibiotics to highly invasive procedures like a heart transplant. This, however, does not equate to us playing gods. It is simply a matter of doctors who have the necessary skills providing help to patients who are free to choose and decide for themselves their own treatment pathway.

P.S. I recognise that other people—including trans and non-binary people—can also be pregnant and need an abortion. I do not wish to exclude anyone.

Access to abortion is regarded as a human right by all the relevant major international organisations. This includes the Royal College of Obstetricians and Gynaecologists, the World Health Organisation, United Nations, Council of Europe, and Amnesty International. 

 

*  Statistics from the Centre of Disease Control and Prevention (U.S.) (2015), Department of Health and Social Care (England & Wales) (2017) and National Services Scotland (2017).

** The Academy of Medical Royal Colleges (2011) reviewed studies from 1990 to 2011; the Charles Reviews (2008) and the American Psychological Association (2009) reviewed studies from 1989 to 2008.

Gilbert Gravino is a Maltese medical doctor. He studied at the University of Malta, obtaining a bachelor of science degree in 2010 and a medical degree in 2015. Currently, he is undertaking further medical specialist training in the United Kingdom.