Hard cases

What about abortion in cases of rape?

What about abortion in the case of disability?

What about life-limiting conditions, or fatal foetal anomaly/abnormality?

What about abortion to save the mother’s life?

What about abortion in cases of rape?

It is difficult to imagine the horror of being subject to such a heinous crime, going through not only such an invasive and often violent violation of the most private part of your body, but also knowing that it might result in something permanent. There are hardly words to describe, and perhaps there aren’t meant to be. Sometimes all we can do is grieve and cry for justice. If you have been the victim of rape, I want you to feel heard, which is inevitably difficult when I’m writing this for a wide audience. If I’ve made a mistake or said something wrong, please do get in touch and let me know. I would be grateful and privileged to hear you share your experiences.

There is a reason non-consensual sex is so awful and degrading. We have evolved with sex at the very centre of our lives, as the only way we continue the human race. It is no surprise that it occupies such a sacred and important place in our lives: and has the potential to have so much power over people. The power of sex to procreate is, arguably, what makes it so sacred – and part of why rape is such a wicked affront to the human being it victimises (of course, there are other elements which make it awful). Feminists are right to say that forced pregnancy and forced motherhood are heinous crimes. The question is: once a woman has had pregnancy forced upon her, can she end that pregnancy? As I’ll suggest with as much humility as possible, that depends on what the ‘pregnancy’ is. I don’t say any of this lightly, knowing that I tread on perilously delicate ground. But at the same time, women faced with this awful situation deserve to hear why it is that pro-lifers have the position they do – especially since such a large number of women in such situations do indeed continue their pregnancy. I’ll try to make some sense of this.

To put this in perspective, it’s worth noting that only a tiny minority of abortions are for this reason. In the most widely cited study, rape contributed to the reason for abortion in 1% of cases, but was the principal reason in 0-4 cases out of 957. More recent data from Florida suggests around 0.14% abortions due to rape. When disability-selective abortion was banned in Poland, it was widely reported that this was 97% of abortions in Poland. Given that disability-selective abortions are themselves extremely rare, this would make abortions for rape in Poland extremely rare – 3% of an already very small number. However, since Poland requires certain measures to authorise abortion in cases of rape, it may be that some victims of rape sought abortions illegally or in another country without obtaining one legally in Poland.

Still, that is not to downplay the importance of this question. This question matters, because those women matter. So what can be said? I think there are two parts to this question: what about the baby? And what about the woman?

We’ll talk about the baby first – not because it is more important – but because it will be shorter and allow me to discuss the situation of the woman at length.

This will only make sense if you understand the pro-life view to begin with. Pro-lifers aren’t pro-life because they find abortion distasteful, or disgusting, or because it goes against their personal beliefs or preferences. They are pro-life because they believe that the unborn child is one of us – a human being with equal dignity and rights. This means that she has to have the same legal protection as the rest of us – no matter how or by whom she was conceived. If you don’t understand the pro-life view, you won’t understand this answer. But hopefully you are on board so far.

Think about it this way, and forgive me for any bluntness. Suppose someone decides to keep their child after being the victim of rape. Suppose that as the child grows up, they begin to acquire recognisable features of the rapist, which brings back traumatic memories for the mother. She does not live in a place where anyone can take care of the child instead of her. So she decides to end its life.

Most people would agree that it was wrong – however much legitimate and understandable distress the woman, who certainly is a victim of heinous crime, experiences. Why? Because this is a child, and children have a right to life even if their existence causes extra suffering to a victim of horrendous abuse. Most of us would even say the same about late-term abortion: late-term abortion – when the baby is viable and conscious, and so on – should not be legal even if the mother has been the victim of a horrendous crime. If someone accused you of being callous or indifferent towards rape victims because of your position on these cases, try to imagine what you would say in response. This might give you some indication of how difficult it is for pro-lifers to articulate their compassion for victims of rape with their insistence that innocent lives must be protected.

We grieve that the world sometimes forces people to put up with such distress, but sometimes it does, and we nevertheless have to balance the fundamental rights of other human beings. Sometimes doing the right thing requires tremendous bravery and courage – far more than I will ever show.

Hence, many pro-lifers and pro-choicers alike have argued that the only consistent pro-life view is to say that children in the womb have to be protected no matter the circumstances of their conception – the same principle we apply to children outside of the womb. This is why the pro-life view has what seems to many people in the West a callous view.

But how callous is it? What does the empirical evidence show about the mental health of rape victims, and the best way to get them the support they need? As a doctor, my first question, after listening to the whole story and getting all the information I need, is: will abortion help the trauma to heal?

It is easy to understand why someone in this situation might panic. That is an entirely natural reaction. It is also easy to understand why someone would want nothing other than to be rid of the pregnancy. It is no surprise that ‘relief’ is the most common emotion after an abortion. This is a crisis situation: and in crisis situations, all you want is to just get rid of the crisis. Abortion is the ‘great reliever’. It gets rid of that immediate problem. But does it get rid of the deeper problem?

We often make decisions in crisis situations which are not ultimately best – for us or for others. And often getting rid of an immediate problem leaves us with the deeper problem unresolved. So our question is: will abortion heal the trauma? And, will the pregnancy compound the trauma?

Probably the biggest risk in discussing questions like these is that we make assumptions without listening to what women in this situation have to say. The more I have researched this area, hearing the testimonies of women and looking at the empirical evidence – which sounds cold and analytical but is really just all those testimonies added together – the more I have come to believe that from a medical perspective, abortion will not help to heal the trauma . In fact, it can make it worse. By contrast, pregnancy will not compound the trauma in the long-term.

There is very little research on the attitudes of rape victims towards abortion – which is quite incredible given what a common topic it is. The closest I have been able to find is a recent study from Ghana, which found that those who had ‘ever had sex when did not want to’ were less supportive of abortion than the average woman (and slightly less supportive than the average man) – only 32.1% said that abortion was justified to save the life or health of the mother. Clearly this is a very conservative country and the results are difficult to generalise.

Abortion is frequently presented as the obvious option after a woman has been raped: the culprit usually has a vested interest in concealing evidence of the crime, doctors frequently assume that abortion is the obvious choice, and families, friends and others often assume the same – in one case, a woman was denied refugee status after having her experience of rape doubted because she kept the baby. It’s therefore significant that a large proportion of rape victims opt to keep the pregnancy. Reardon et al. present the results of a survey of 192 women who were the victims of rape or incest, where pressure from others was a recurring theme. And yet in his sample, 73% of the rape victims chose to continue the pregnancy, along with 50% of the victims of incest (with a fairly broad distribution of raising the child vs placing for adoption). In Holmes’ study, 50% of the women had abortions, and in Mahkorn’s study, at least 75% of the victims continued the pregnancy. Since these studies, and especially in the developed world, social safety nets have improved dramatically, as has treatment for trauma victims. We might reasonably suppose that the psychosocial prospects for continuing a pregnancy in such circumstances have improved dramatically.

What does the evidence on mental health show? As I showed in ‘Abortion and mental health’, there is now clear evidence that abortion is associated with worse mental health outcomes than continuing an unwanted pregnancy, after controlling for other variables. Even those who doubt these findings admit that there is no evidence that abortion improves mental health, on average, in these circumstances.

Unless there is good reason to suppose that this trend would be different among rape victims, we should provisionally accept the evidence relating to the general population as indicative of outcomes among rape victims (though, of course, rape victims will have poorer mental health outcomes in general). The main reason one might think those continuing a pregnancy might have differentially worse outcomes especially in the case of rape is the prevalent idea that bearing a child after rape will compound the psychological trauma of rape by acting as a reminder. As we shall see, however, the psychiatric evidence does not bear this idea out.

Given this surprising initial statistic, it is worth considering whether our assessment of the psychology of rape victims is based more on prejudice rather than on the empirical data. In a small study, Mahkorn looked at the psychology of a sample of rape victims, most of whom continued the pregnancy. She found that only a small minority of them felt, at any point, that the child would be a continual reminder of the event. By far the greatest contribution to the felt necessity for abortion was social stigma. This reminds us of the importance of non-judgmental attitudes towards those who are unexpectedly pregnant.

It is significant that the most cited problematic element of pregnancy is shame and guilt, which so frequently characterise the distress from abortion. Closely related is the need for rape victims to be able to talk about their experiences, and their need to feel that their experiences are not ‘taboo’. Abortion can, of course, contribute to this sense of ‘covering up’ and keeping taboo what has happened. Other features of rape trauma include loneliness and defilement, both of which can be exacerbated by abortion. As described, abortion is frequently pushed on rape victims, likely contributing to their sense of helplessness.

Perhaps the most salient feature of Mahkorn’s study is the time-relative component. Not a single woman in the study changed from a positive view of the pregnancy to a negative view, whereas most who began with a negative viewpoint changed to a more positive viewpoint during the pregnancy. Overall, there was a large increase in psychological wellbeing across a number of parameters over time. Again, given the developments in trauma treatment, social attitudes and pregnancy support since the study in 1979, we should expect that the psychological improvement over time would be far more pronounced today.

Reardon’s study makes broadly similar points: many of the specific symptoms of rape trauma are those which could easily be compounded by abortion. His book presents a representative sample of the testimonies of women included in his study. Most of the women in his study who had abortions regretted it, and every single woman who continued the pregnancy was glad she did so; this is consistent with the Turnaway study finding that 96% of those who were denied abortions were eventually glad they had the child (98% among those who raised the child). While it is unlikely Reardon’s sample is representative of all rape victims, nevertheless, the study was open to, and included, women who did not regret their abortions. And the reasonable sample size militates against these responses being wildly anomalous. In any case, the testimonies given by the women are important: testimonies confirming how abortion in many cases compounded the trauma of rape, or in the case of continued pregnancy, confirming how the baby ended up being the only thing that made sense of their experience, even in cases where the woman initially attempted to have an abortion. The following sentiment was not unusual:

“Abortion does not help or solve a problem – it only compounds and adds another trauma to the already grieving victim. It only takes away the one thing, her child, that can bring joy.” Helene Evans, rape survivor cited in Reardon.

One of the most powerful ways of dealing with our suffering is to fit it into a narrative, to find meaning in it and make sense of it. Hence Dan McAdams makes a powerful case for seeing redemptive narratives as central to psychological wellbeing: ‘the main results of the study showed that, for both the adults and the students, the more redemptive the life story, the better a person’s overall psychological well-being’. And it is clear how a child could be a redemptive experience in a way that an abortion could not. This is not removed speculation: this is based directly on the many testimonies of rape victims who have said precisely that. They should not be lightly dismissed.

No one is saying that this is an easy fix to the trauma of rape. There is no easy fix – rape victims have been subject to horrendous trauma which requires immense support, which is all too frequently missing. But the same point cuts both ways: having a child, though often a healing and redemptive experience, is not an easy solution to the trauma of rape. But neither is abortion. The question is, therefore, not whether a victim of rape will suffer immensely. They obviously do. The question is whether there is any evidence that abortion offers better prospects for healing the pain than continuing the pregnancy. At present, there is no empirical evidence for this position.

To come back to our original question, then: will abortion help heal? The woman assaulted in this way has been through a trauma regardless of what happens to her pregnancy: that trauma will not be removed by abortion. What the limited evidence we have does show is that there is no evidence abortion improves mental health for unwanted pregnancy, and significant evidence it makes it worse. By contrast, women in this situation who keep the baby rarely, if ever, seem to regret it, and often report that the baby was the only thing that gave meaning to their suffering – a profoundly important part of recovering from trauma. The evidence we do have suggests that although abortion is a natural reaction to rape, it is in fact not as common as thought, and when women are given time and support, they are usually able to see the baby as an opportunity to find meaning in their trauma, as a way of conquering the hatred and evil inflicted upon her by the rapist.

All this suggests that abortion is not the best solution to rape. Rape is an appalling injustice and victims of rape deserve society’s utmost compassion and support. The low conviction rates for rape are likewise harrowing. But not only is there no evidence that abortion helps in these situations; it also redistributes the injustice rather than resolving it. If we accept that the child is a human being, then that life has to be protected regardless of its circumstances – as we would all agree in the case of late abortion or a born child. What we are saying when we make an exception in cases of rape is that those born from rape are less deserving of legal protection than other people. Abortion, therefore, adds a second trauma to the victim, and a second victim to the crime.

I’m only too aware that, as much as I have tried to listen to victims and respond with compassion as best I can, I may have made mistakes. Please do forgive me if so, and please share with me how I could say this better. I’m also aware that as a man who will never be in this position, it can come across as ‘easier said than done’, and I will never have to put my money where my mouth is. I’d therefore highly recommend reading and hearing the stories of those women who have been in that position, or children who were born as a result. David Reardon’s book Victims and Victors is perhaps the best place to start, but Jennifer Christie is another woman who was raped and speaks regularly on this issue. There are many more besides these. Thank you for your patience.

What about abortion in the case of disability?

By this point, if you’ve read what I’ve written on the value of life, the answer to this question should be relatively clear (we will discuss life-limiting conditions, or ‘fatal foetal anomalies/abnormalities’ separately below). All human beings are equal regardless of their ability – and this obviously includes people with Down Syndrome, Turner’s Syndrome, limb malformations, and so on. Most of us are rightly appalled at the thought of sex-selective abortion. But many still have a tolerance for disability-selective abortion, originally known as eugenic abortion. It is hard to reconcile these positions for anyone who genuinely believes in human equality.

I am writing a paper on this topic which I hope to make available shortly.

What about life-limiting conditions, or fatal foetal anomaly/abnormality?

This is a more challenging question. Some disabilities cause serious physical problems so that the child is unable to live for very long at all – sometimes dying in the womb, sometimes dying shortly after birth. This requires a more substantive response: many people understand that abortion for babies with Down Syndrome, for example, is wrong, but feel that keeping a baby alive who is destined to die in a very short time anyway is pointless, and maybe even uncompassionate given the suffering it may experience. It is often portrayed as cruel to ‘force’ a woman to carry a child to term, knowing that the child will die. Certainly these diagnoses are harrowing and can involve great suffering. But as I will show, the empirical evidence shows that abortion in such cases involves significantly worse suffering.

It is interesting to see how this debate has changed over time. Down Syndrome itself used to be seen as a life-limiting condition (and the life expectancy is still shorter than average), but of course we all now know that people with Down Syndrome are equally valuable and have lives that they value themselves – around 99% of people with Down Syndrome are happy with their lives, probably a higher percentage than the average person. Life expectancy has enormously increased.

Other conditions still seen as ‘fatal’ are moving – much more slowly, and generally with lower cognitive capacities – into similar territory. For example, the latest research shows relatively high survival rates for children with Patau (trisomy 13) and Edwards Syndrome (trisomy 18) when they are actually given treatment – in many cases, their low survival chances are a self-fulfilling prophecy: survival rates are low because they are not given treatment. The same research likewise shows that parents are generally very glad to have brought their child into the world, and find their experience nothing like the negative stereotype created by healthcare providers. 98% said that their child enriched their life, and 82% said the child had a positive impact on their other siblings. Only 8% said that they would not continue the pregnancy in a similar situation in future. Even with conditions often thought to be the most severe, like anencephaly, where the top of the brain, or a significant portion of it, fails to form, there have been cases of children living up to 2 years or more (picture of child with anencephaly at 21 months). Parents often describe how their child is nothing like the picture presented (visually, emotionally, or otherwise) in textbooks.

The argument that the child would be better off not surviving involves highly questionable assumptions. Our assumptions about the lives of people with disabilities are usually wrong: even patients with locked-in syndrome, preventing any movement other than eye movement/blinking, typically say they have a good quality of life. As mentioned above, 99% of people with Down Syndrome are happy with their lives.

Moreover, perinatal palliative care is now extremely effective, such that it is rare for babies in such situations to suffer horrendously – though of course they often do in late-term abortions (abortion for life-limiting conditions typically occurs at a late stage). Hence the argument that abortion is better for the child themselves has no basis in reality.

It is worth drawing attention to the empirical studies of parents who have chosen abortion in these difficult circumstances, compared to parents who have chosen to continue the pregnancy.

In fact, the evidence we have suggests that abortion in the case of life-limiting conditions leads to worse psychological outcomes than continuing the pregnancy. A recent study from Wool et al. found that the overwhelming majority of parents who kept a baby with a life-limiting condition had no regret about their decision to continue the pregnancy. Wool and others have described the positive and redemptive feelings experienced by many mothers in the situation. Cote-Arsenault and Denney-Koelsch published similar findings in the Journal of Palliative Medicine, noting that the results were not dependent on any prior factors such as religiosity. Other authors have likewise emphasised the importance of constructing lasting memories with the baby for positive psychological outcomes. This video is a compelling example of how families can find an experience with a child who never learns to speak and lives only a short time to be a profoundly meaningful and joy-giving experience, despite the tragedy of the situation as a whole. I highly recommend watching it.

By contrast, psychological outcomes after abortion in such circumstances are usually poor. This is to be expected, since these pregnancies are usually wanted, and aborting a wanted pregnancy is usually associated with far worse outcomes.

A 2017 paper in Midwifery documented the experience of delivery after abortion for foetal abnormality from a larger group of studies, describing overwhelmingly negative experiences, and the importance of spending time with one’s baby after delivery. Interestingly, given that some have argued that continuing a pregnancy in such a situation would constitute ‘torture’, one of the themes of delivering the aborted foetus was specifically that of torture: ‘No one can understand the torture’, ‘One of the worst things in my life’, ‘There was no hope’, ‘I thought I would die’, and so on. These are significantly different from the deeply grievous but also paradoxically satisfying experiences of continuing the pregnancy. In the latter case, there appears to be no indication of torture.

Similar themes are re-iterated in an evidence review conducted by the National Institute for Clinical Excellence in the course of generating guidelines on abortion. The experiences highlighted as characteristic were much the same:

“Most of the women were not able to work or do anything… ‘I had a hard time to focus the first three months after termination; everything felt quite meaningless’”

“Most [women] find grief intensifying for the first 3-6 weeks and lasting until the due date.”

“Several reported that genetic counsellors ‘saved my life’ by getting the patient pulled out of her isolation”

“The women regretted the abortion to and fro and some of them expressed thoughts that they would never become normal again.”

“Support after the termination was essential to the way women coped”

“I feel completely alone in my grief as no one seems to understand just how profound it is.”

“If she hadn’t followed up, and if she hadn’t seen how upset I was, and if she didn’t say she’d get the names and numbers of groups to me… I’m not sure I would have ever come out of the cave.”

“Everything I was feeling – anger, alone, guilt, the hatred of pregnant women – was completely natural and that everyone went through it”

“I needed help. My life was upside down.”

The finding that grief lasts until the due date is particularly important. It demonstrates that the primary alleged benefit of abortion – that the death will occur earlier and therefore curtail the suffering of the woman – is non-existent. Whether a woman continues her pregnancy or not, her grief will persist until the due date. Abortion will not truncate this process.

Other reviews of studies on this topic show the same general conclusions, including that abortion in such circumstances should typically be considered a kind of trauma.

Finally, there is one recent study which directly compares the psychological outcomes of women making both decisions after such a diagnosis. It found clearly that continuing the pregnancy was associated with less despair, avoidance and anxiety than having an abortion.

In summary, then, the evidence that abortion helps women in this distressing situation psychologically is extraordinarily slim. On the contrary, there is some powerful evidence that continuing the pregnancy is likely to contribute to better psychological outcomes.

These situations are always profoundly distressing. Many of us are fortunate never to have experienced the loss of a child in such circumstances. But from a medical and psychological point of view, there is no basis for suggesting that abortion is the preferable option in such cases. On the contrary, continuing the pregnancy – with good support from friends, family, and doctors – is best for both the mother and child.

Again, I have a working paper on this topic which I hope to make available shortly.

What about abortion to save the mother’s life?

Virtually every pro-lifer believes that abortion to save the mother’s life should be legal, though many think that ‘abortion’ is an inappropriate term for such situations, since they consider ‘abortion’ to imply intentional killing. Rather, they say that this should be described simply as premature delivery, or evacuation. I won’t enter that debate here; for ease I will use all these terms interchangeably.

It is worth noting at the beginning that abortion in these cases is legal in virtually every country in the world already, and no pro-lifers are seeking for that to be changed. Even in countries which do not formally allow abortion in such cases, such abortions are clearly allowed under common law – as in Malta, where such abortions take place perfectly legally despite there being no formal statutory provision for them.

Such abortions are extremely rare. Of over 200,000 abortions a year in the UK, just over 100 are to save the life of the mother, or prevent grave permanent injury, combined. As noted under ‘Why do abortions occur?’ and ‘Is abortion on demand legal?’, because of the phrasing of the law, it does not require a serious risk to the mother’s life, and many abortions ‘on demand’ were carried out under this clause in the early years of the law. So it is difficult to say how many of these were genuinely life-threatening. But since abortions in the UK legally require certain specific details, we do have considerable information about the diagnoses from Freedom of Information requests.

For example, in 2017, of 102 abortions on the basis of risk to the mother’s life, 34 were beyond 20 weeks. Beyond 21 weeks, babies can potentially survive outside of the womb – so it seems the obvious moral thing to do in this case is deliver the baby and attempt to save it with neonatal intensive care.

In terms of diagnosis, 6 were for cancer, 5 were for ‘mental illness not otherwise specified’, 9 were for cardiovascular disease, 4 were for ectopic pregnancy, and 48 were for other obstetric conditions, such as pre-eclampsia, haemorrhage, and sepsis. For 23, no reason was given. It is impossible to tell without further clinical details how many abortions in total were genuinely needed to save the life of the woman. It is likely a significant proportion were not – one abortion was done for high cholesterol, for example, and it is difficult to see how this could have been an acutely life-threatening condition. So it is clear that 102 is an absolute upper bound for life-saving abortions.

Likewise, there were 86 abortions done to prevent grave permanent injury to the mother. But 44 of these were for ‘mental illness not otherwise specified’ and for 8 no reason was given. The previous year 147 were performed under this clause, but no reason was given for 59, and 44 were again for ‘mental illness not otherwise specified’.

Beyond 21 weeks – the current viability mark – there is obviously no reason to end the child’s life, or to allow it to die. If the woman’s life is under threat from the pregnancy, the baby can be delivered and then given intensive care to try and save its life as well.

Before 21 weeks, things are more complicated. In the vast majority of cases, the baby is tragically destined to die regardless, since it would die if the mother died, and the mother is at risk of imminent death from, for example, sepsis. Since the baby will die either way, it makes sense to save at least one life, that of the mother, by delivering the baby.

In a vanishingly small number of cases, there may be a decision to save the mother or the child. For example, if at 20 weeks, the mother develops a condition which requires delivering the child, but could potentially hold on for another week or two, at greater risk to herself, in order to save the baby. In these rare cases, there is some disagreement about when delivery would be morally acceptable – but virtually everyone is agreed that delivery should be legally permitted. Either way, these cases tend to be more a balance of risks (bearing in mind that in most of these cases, the mother wants the baby and not infrequently will voluntarily sacrifice her own life) rather than a straightforward decision of whom to save.

There is some debate about why exactly these abortions are justified. There are four broad options: first, they could be considered as self-defence. Second, they could be considered necessary (a complicated defence to murder in English common law). Third, it could be argued that the baby is not being killed, since the baby is on a fatal trajectory already. Fourth, it could be argued that the baby is not being intentionally killed, and its death is a proportionate foreseen consequence of delivery. I make no judgment here about which of these is correct.

It should be noted that the numbers cited here are much higher if ectopic pregnancy is included – normally, it is not included because in UK abortion law, ectopic pregnancies (ironically) do not count as pregnancies, since they (by definition) are not implanted in the uterus. These cases are all of the ethically simple kind, however: the chance of a woman holding out until viability with an ectopic pregnancy is vanishingly small (though has occurred on occasion) and hence the baby is almost guaranteed to die regardless of which action is taken.

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