Friday, 9 July 2010

A dilemma

I find dealing with termination of pregnancy requests difficult.

The first problem comes with how to react to a patient's opening statement of "I think I'm pregnant". My usual response is a wide smile and congratulations all round, but clearly if the pregnancy is an unhappy mistake this is not the way to go. You do usually get some pointers that you need to tread carefully, but it's not always easy.

The next problem comes with trying to fit a decent 'pros and cons of having a baby' conversation into a surgery appointment. To be fair, most women have already decided what they want to do by the time they come and see me, but it's such an important decision that I like to be able to spend some time with them none the less.

My final problem is in signing the document. For those of you who don't know, terminations can only go ahead if they have the signature of 2 doctors, both stating that they feel termination is appropriate. Up to 24 weeks of pregnancy, termination is allowed on any of the following grounds:

a) If continuing the pregnancy poses a risk to a woman's life, or
b) to her physical or mental health, or
c) to the physical or mental health of her existing children.
d) If the baby is at substantial risk of being seriously mentally or physically handicapped.

My problem is that if we're being completely honest, many terminations go ahead without fulfilling any of these requirements. So when a woman asks for a termination because she is at university and doesn't feel that she can cope with a child in her present circumstances (a situation that I sympathise with enormously), I do wonder which category she fits into. Will it really affect her mental health if she has a baby? Might it not affect her more if she terminates and later regrets it?

It's not my position to stand in the way of a treatment that is readily available now in this country, but I'm afraid that I don't sign the form. I send the patient on to someone who will, but I don't do it myself.

Now you could say that this causes extra inconvenience for the woman and given that she will go on to have the termination with or without my signature, is there any point in what I am doing? Am I just being self righteous?

On the other hand at least I'm being honest with myself and in truth termination clinics are usually well set up for this eventuality, themselves having 2 doctors present who can sign the form. I know it's not ideal and I've no doubt there are many who disapprove of 'conscientious objectors' like myself, but it's a dilemma that I don't know how else to deal with.


  1. How difficult. When someone says they are pregnant, I ask them how they feel about it. If happy then I congratulate. And if not then we talk about it.
    We have a local service which should mean that we don't have to sign the forms either. But sometimes women do come back and say that they were told we would sign them.
    I used to sign them in a detached kind of way. But my own fertility issues have become more of an issue. I can never carry a child. This should not influence how I respond to termination requests but I am human. A few weeks ago I did complete the form for a woman who has very definite mental health issues. Of course she may regret the termination later. I might have done the wrong thing. It is so hard to say.

  2. They are adults who know their own circumstances and history best, so your role is to refer/provide a legal, common and safe medical procedure no? I think medical practitioners get themselves into an unnescessary gray area by adding morality to fairly clear legal guidance.

    As for the mental health effects of pregnancy - the Guttmacher Institute is a good source on these things:

  3. Sarah,
    The UK does not have abortion on demand. Under current law doctors are required to make the decisions described above. It has not been described by Pondering Practtioner as difficult because of morals, but because it is hard to see how one can really predict what the effect of pregnancy may be on mental state for any individual. You say that the woman should be left to decide this but that is not what the current law states.

  4. Hmmm, it's always going to be a subject that people have strong feelings about... The worrying thing is that we do seem to have abortion on demand in the UK, although not 'officially'.

  5. We have de facto abortion on demand which is not at all fair on doctors whose patients expect them to perjure themselves.

  6. We have de facto abortion on demand which is not at all fair on doctors whose patients expect them to perjure themselves.

  7. My understanding (from the point of view of studying this as a politics student rather than a medical one) is that as _any_ pregnancy carries a (very small) risk to the mother, effectively we got abortion on demand more or less by mistake through poorly drafted legislation. Since then, attitudes of society has moved on so we've probably got the situation we would have got had we drafted it with a woman's right to choose in mind. It's a very British sort of fudge and I don't envy you your part in it but given how contentious abortion is, tidying up the law now would probably be impossible - as a vocal minority would hijack the process - so unfortunately doctors are stuck with their role in the whole affair.

  8. My mother is a doctor and has always done the same thing as you. Unless there are genuine medical implications she is not comfortable signing the form and refers her patients to another doctor.

    I agree with this. When a decision is not based on medical grounds I don't think a doctor should be forced to sanction it, particularly when it conflicts with their own moral code.

  9. i too have this issue - I am a GP - and I am a Christian and don't believe in ending life, however I also believe in personal choice. After a few years struggling with this, I do refer patients to the relevant clinic, as I feel that by being consulted in the first place, I am implicated in the decision/outcome, whether or not I choose to participate directly (ie sign the form). By asking the woman to see someone else I am implicating another person in this horrible situation.. I wrote to the local clinic explaining why I would refer but not sign the form; they were very gracious and thanked me for my effort to communicate with them - too many GP's don't bother and just send the patient. I also see it as a chance to encourage women to think again, and there is evidence that women do regret abortions later in life and perhaps suffer more mental harm than those who have their babies. Food for thought...

  10. You are doing the best you can.

    To start with you have a very valid point when you suggest terminating can affect more the mother's mental health than not doing it.

    you actually are supposed to sign because you agree, if you don't feel it to be the right thing, you have to derive to another professional.