Many of us can sympathise with abortion when a woman’s life is at risk. But the proposed law in Malta goes far far beyond this, opening the door to abortion on demand.

I graduated from the University of Oxford medical school and for the last 5 years have been a researcher at the University of Oxford working specifically in abortion policy, as well as working in hospital. I can tell you with full assurance that the proposed law in Malta would be a wide open gate to abortion on demand. I know this because I am a doctor and abortion researcher in a country which legalised abortion only for ‘health’ reasons.

In my country, 1 in 4 pregnancies (excluding miscarriages) end in abortion, nearly half of which are repeat abortions – in some cases people have 10 or more abortions. In my country, 200,000 abortions occur for ‘health’ reasons every single year – enough to wipe out the population of Malta in just two and a half years.

Fewer than 100 of these are because the woman’s life is at risk. 98% are for ‘mental health’ – which can mean anything at all (they explicitly say ‘mental disorder – not otherwise specified’). If you say that having a baby girl (as opposed to a boy) would affect your mental health, you can have an abortion in the UK, as our Doctors for Choice organisation has clearly stated. We know that babies are aborted because they are intersex as well. I know of cases where abortions have occurred because a pregnancy would interrupt with someone’s beach body during the summer. Our biggest abortion provider explicitly says that any reason except sex-selection is an acceptable reason for them: ‘any reason other than the sex of the baby is a valid reason to us, but we need to attach it to a legal reason such as, emotionally it’s not the right time for you.’ ‘Health’ clauses are far too vague and allow abortion on demand – from which there is no coming back.

All this is legal up until 6 months of pregnancy in the UK – even beyond viability. But in the proposed Maltese law, there is no gestation limit at all. Abortion would be legally permitted for virtually any reason up until the moment of birth, or even during birth. Most of the other safeguards in the UK law – limited though they are – are missing in the proposed Maltese law as well.

This law is also unnecessary. Abortion is already legal (by common law, not by statute) in Malta if a mother’s life is in danger – this is why women who have chorioamnionitis or other life-threatening conditions with a previable baby have those babies delivered prematurely in Malta, with the babies sadly passing away. The top judges and top gynaecologists in Malta have consistently and repeatedly said that this is the case. If that law is not followed, it is either because the mother’s life was not really endangered, or because of clinical malpractice. It is impossible to determine which is true without all the details – which is why those advocating for abortion will never release the details of the cases they are using to justify changing the law. Either way, neither of these situations requires abortion on demand to solve – at most, they need better clinical guidance for doctors. If Maltese court precedent needs to be explicitly stated in the law, there are far better ways to do it, with far more safeguards and far less chance of abuse, than the proposed law here.

Those are just the headlines. But in case you are not convinced and want to know more, here is just some of the evidence that this will open up abortion on demand:

First, this is what UK politicians and doctors explicitly said even just within a few years of the ‘abortion for health reasons’ law being passed in 1967. By 1970, the Royal College of Obstetricians and Gynaecologists said:

“When the Abortion Bill was under discussion its advocates repeatedly assured the Houses of Parliament that abortion on demand was not their object. Had they done otherwise it is unlikely that the Bill would have become law. Once the Bill was passed, however, there has been a persistent and intense

campaign which has had the effect of making the public believe that any woman has a right to have a pregnancy terminated if she so wishes… Had our advice on the phrasing of the Bill been heeded many of the abuses which are now worrying its sponsors’ would have been prevented. They were anticipated by this College, and its representatives repeatedly gave warning of them.”

As Professor John Keown wrote in his Cambridge University Press book on the history of abortion law in England, within just 4 years of the law concern about abortion on demand was being raised everywhere within the medical profession – by the British Medical Association, the Royal College of Obstetricians and Gynaecologists, and in all the leading medical journals. They noted that in the private sector, only 1% of requests for abortion were refused.

Indeed, the abuses of the Bill were so clear that even the author of the Bill himself, David Steel, stated that “Abortion is, I am afraid, being used as a contraceptive. The present level is too high.” Elsewhere he noted: “It is odd that so many women present for repeat abortions, some more than twice, which does suggest they are treating abortion as contraception. This was never the purpose of the 1967 reform.”

More recently, the former CEO of BPAS, the UK’s leading abortion provider, said that “Despite being one of the most restrictive laws in the developed world on paper, it is one of the most liberal in the way it can be interpreted. Although the Act does not formally permit allow abortion on request, that is close to what it allows in practice.”

Likewise, the editor of the British Medical Journal Sexual and Reproductive Health said: “The idea of predicting mental health outcome with confidence, against a woman’s own testimony, is inconceivable for most practitioners. Applying the law as it stands, we can at best inform a woman of what the law requires, inquire sensitively whether she believes it to be fulfilled in her case, explore doubt conscientiously, inform her of risk, and trust her response.” (Italics added)

When abortion activists were campaigning for legal abortion in Gibraltar a few years ago, the leading Member of Parliament seeking this change explicitly copied the UK and said that: “The proposed new section 163A.(1)(a) will provide for abortion to be lawfully provided where two ‘registered medical practitioners’ certify that a pregnancy has not exceeded 12 weeks and the continuance would involve a greater risk to physical or mental health than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman. It mimics the letter of the law of other jurisdictions including the UK. But we all know that this is a loophole through which abortion happens on-demand within the established time parameters”.

Second, we know that in many cases – perhaps even usually – women are not seen or spoken to by a doctor when abortion is considered in the UK. Government guidance says: ‘there is no statutory requirement for either doctor to have seen and/or examined the woman’. A newspaper investigation found that abortions were being signed off after 22 second phone calls, with women saying nothing other than ‘I just don’t want the baby’.

Third, we know that there was even a practice at one of our leading providers of pre-signing abortion forms en masse before the doctor had even spoken to the woman. They were given a slap on the wrist – but it is a clear indication that this is abortion on demand.

The same abuse has occurred in many other countries. In Ethiopia, abortion is officially allowed if ‘the continuance of the pregnancy endangers the life of the mother or the child or the health of the mother’, but leading pro-abortion researchers in the country declared that ‘all women know that safe abortion is available and legal for many indications’ and that ‘In most cases, a woman’s statement is sufficient to establish the legal indication for, and allow her to obtain, the abortion’.

In New Zealand, until recently abortion was allowed if ‘the continuance of the pregnancy would result in serious danger (not being danger normally attendant upon childbirth) to the life, or to the physical or mental health, of the woman or girl’. But 97% of abortions – nearly 13,000 – were done for mental health reasons under this clause in the country – a country of only 5 million people.

Many other examples could be cited (e.g. Ghana and Australia), but the evidence is clear: ‘health’ includes ‘mental health’, and when this is included as a reason for abortion, virtually any reason for abortion counts, as long as the doctor is willing – and there is always a doctor willing.

The fact that the proposed Maltese law refers to a woman’s life being put in ‘grave’ jeopardy is not a real safeguard. First, it explicitly says that an abortion can be done if the woman has a condition which may put her health in grave jeopardy – not if it is likely to be put in jeopardy. This is an extremely low bar – any condition at all, including pregnancy, could put someone’s health in grave jeopardy – that does not mean it is at all likely. This would allow abortion for any reason at all.

Indeed, it was precisely this kind of argument which British doctors used to perform abortion on demand after legalisation. Another British abortion law from 1967 allows abortion if there is a risk to the woman’s life from the pregnancy, greater than the risk of abortion. Some doctors reasoned that pregnancy is always riskier – though still very low risk – and therefore abortion is always allowed at any stage in pregnancy. As Keown points out, these doctors carried out this principle in practice, performing abortion on demand for any reason at any point in pregnancy – and were legally allowed to do so.

Second, these qualifiers typically have no clear legal meaning, and are rarely, if ever, upheld legally. The New Zealand law mentioned above requires a risk of ‘serious’ danger and even explicitly says that this should not be ‘danger normally attendant upon childbirth’, and yet still clearly allowed abortion on demand in practice. Likewise, the UK law allows abortion up to birth if there is a substantial risk of a ‘serious’ handicap to the baby – but in practice any disability is grounds for an abortion, including cleft lip or cleft palate.

In fact, when scholars warned that the UK law could allow abortion for cleft palate, David Steel called this idea ‘totally discreditable’, and other MPs said that it was scaremongering and that the scholars should be reported to the Bar Council. The authors of the Bill claimed that it was only meant for children who were ‘incapable of living any meaningful life’. But we know that abortions occur for cleft lip, cleft palate, and a quarter of disability abortions are for Down Syndrome. The disability does not even have to be proven – there merely needs to be a risk.

All this shows that the Maltese law, as currently drafted, is profoundly dangerous. Most likely, it is an attempt to legalise abortion on demand by stealth. If not, then the government must allow a re-drafting by legal and medical authorities who value unborn life – including the finest medical and legal minds in Malta. These people all support evacuation of the baby when the life of the mother is threatened, and would be happy to help draft an alternative law. The failure of the government to defer to them would demonstrate a clear motivation to legalise abortion on demand by stealth. Pro-lifers cannot allow this to happen under the false guise of protecting women’s lives.

If you’ve been raised in a Western culture, your impression of pro-lifers is probably a bad one. At best, they are hopelessly out of touch with the realities of the modern world – aliens, in a sense. At worst, they are wicked misogynists wanting to return the world to an oppressive patriarchy in which women have virtually no rights or status. Even if you’ve reached maturity elsewhere in the world, if you have social media (as you probably do, reading this), you’re likely acquainted with such sentiments.

While I never had such a deep cynicism towards pro-lifers, nor was I always pro-life. I don’t know if I ever thought the pro-life view was cruel – I knew pro-lifers who were clearly not – but I did think it was unreasonable. Having gone into Medicine as a proudly radical left-winger, wanting to work in global health to alleviate suffering among the most ignored and despised human beings in our world, I never anticipated that I would end up speaking and writing mostly about abortion.

Yet here I am, trying to convince you to follow the same pastoral and intellectual path I took during my time at Oxford medical school, which I became firmly convinced offers the most compassionate, humane, and reasonable response to women feeling trapped in a crisis pregnancy situation. Not only was I convinced that the pro-life view was correct: I was persuaded that this was a centrally important issue for anyone with a concern for the last, the least and the lost in our world.

This page is an ongoing project to try and provide humane, reasonable, and concise answers to those sincerely seeking to understand the pro-life view – and maybe even open to following the arguments where they lead. The answers won’t be comprehensive – that will come in a later book – but I hope they offer a helpful starting point. I acknowledge that this view will seem counter-intuitive to many people, and that abortion has been so widespread for so long in the West that it is difficult to believe that we could be so mistaken about it. But all societies throughout history have been completely wrong about at least some centrally important moral questions. It would be extremely strange if ours were the only society that was right about all of them. So all I ask for is an open mind. In response, I will do my best to take seriously the claim that women’s equality in the last 50 years has been based on abortion, and to offer serious responses to those – especially women – whose lives may be greatly complicated by an unplanned pregnancy.

So what is the pro-life view I am suggesting? Importantly, it is not that unborn babies are more important, or entitled to more rights, than the women carrying them. That would, in fact, directly contradict the pro-life view, which says that all human beings have equal inherent value, and equal fundamental rights. Although most people claim to accept this position, most (in the West) do not accept that embryos and foetuses have equal inherent value and fundamental rights. So my task here is to convince you that it is impossible to accept a standard vision of human equality without extending that vision to human beings in their earliest stages of development.

This pro-life view says that both lives matter infinitely, and that the mother’s and child’s wellbeing are inseparable. It claims that we need not pit mother and child against each other, as if their interests were in conflict, but that there is a middle way which genuinely dignifies and supports both, without the need for loss of life.

One of the fascinating things about this debate is that almost everyone who considers themselves pro-choice, especially in Western Europe (the US is a bit different), thinks that abortion should be limited in certain circumstances. Almost no one thinks, for example, that having an abortion in the third trimester because the baby is a girl should be legal. In the UK, almost no one thinks that having an abortion in the third trimester in general should be legal (the same polling shows, incidentally, that women are more supportive of limitations on abortion than men). This is clearly in some sense an ‘anti-choice’ position – they are against women having the choice to abort a baby at, say, 36 weeks, because it is a baby girl. Yet all these people would be reluctant to consider themselves ‘anti-choice’. And most of us would not call them that. Nor would we call them misogynists or patriarchs or religious nutters. When I debated a panel of four leading pro-choice advocates on a leading BBC show a few years ago, only one of them supported allowing abortion after 24 weeks. But no one was rushing to call them ‘anti-choice’. Nor did they do so when the UK’s leading parliamentary advocate for abortion put forward a Bill to decriminalise abortion, which included a new provision to ban abortion after 24 weeks, with a possible punishment of imprisonment for life.

You will have your own view about when abortion should be limited. For the purposes of this point, it doesn’t matter what your exact line is. The point is that in supporting those limitations, you are – from another perspective – limiting the choices of women. Maybe for a small minority of the readers, this realisation will move you to the extreme end of the pro-choice position – that abortion really should be legal for any reason, at any point in the pregnancy. But for most people, the intuition against late abortion is more resolute. Most people cannot look at the videos, or consider the science, of babies late in pregnancy and seriously believe that it should be legal for their lives to be ended, despite the burdens they might place on the woman who carries them.

What does all this mean? It means that the overwhelming majority of Western pro-choicers agree with pro-lifers on a certain principle – namely, that when an embryo or foetus reaches a certain status, it can be considered a person and should have the protection of a person – and that this includes protection against abortion. It shows that the pro-life position is not as radically different from standard public opinion as it often appears: all it says is that this point is earlier in development than many in the public think. It reveals that for most people, the fundamental question really is about what the embryo or foetus is and what value/rights it has: if it is a person of equal value to the rest of us, then it should have protection. If you’re struggling to understand how pro-lifers can be OK with limiting people’s choices, this may be the most helpful starting point. (If you really do think that abortion should be legal at any point in pregnancy for any reason, we will examine that position in the Q&A).

You may be on board with this reasoning. You may openly agree that, in principle, abortion could be limited at a late stage, or for certain reasons (e.g. sex-selective abortion), and that supporting some restrictions on abortion is not inherently anti-choice or misogynistic. Your puzzlement may be at pro-lifers having such a low threshold for limiting choice: limiting choice makes sense when there is a fully grown, sentient baby capable of feeling pain and interacting with its mother, as in later stages of pregnancy (arguably the second trimester as well as the third). But how can pro-lifers believe that this protection should start at conception?

To answer this question it will help to go back to international human rights law. One of the foundational treaties codifying the Universal Declaration of Human Rights into binding law is the ICCPR, in which Article 6 reads: ‘Every human being has the inherent right to life. This right shall be protected by law.’ This article therefore asserts both a right to life and its legal implications: that right must be protected by law. It is not a matter of ‘personal choice’ or anything like that – the right to life needs objective legal protection.

But to whom does it apply? This is not a trivial question: to the Greeks and Romans before the Christian period, it would obviously not have included born babies. Today, the foremost moral philosophers writing in defence would be inclined to agree. Nor would it necessarily include certain disabled people who have less sophisticated cognitive abilities – and again, many contemporary moral philosophers would agree. Of course, for most of history, it would not even include plenty of able-bodied/minded mature adults: slaves and those of other races/nationalities may well be exempt. And while women have often (though not always) had a right to life throughout history, they have rarely been considered persons with full equality under the law. The modern ‘consensus’, if it could be called that, is a relatively recent and unusual innovation.

All these groups have been considered subhuman, or not human at all. But we now recognise that the exclusion of some human beings from the scope of human rights has, in virtually every case, constituted a moral atrocity. By contrast, most of the major advancements in human rights throughout history have resulted directly – and often explicitly – from the recognition that being human makes one part of the human family, and therefore in the scope of protection from the rest of that family.

Of course, international law as we now know it resulted directly from one of these atrocities – the horrendous dehumanisation and abuse which precipitated the second world war. This abuse was directed most clearly against the Jewish people – but also against disabled people, gay people, Slavs, and others. Modern human rights arose out of the recognition that no matter someone’s skin colour, ethnicity, sexual orientation, or abilities, if they are a human being, they matter – they are equal, and deserve basic human rights.

In order to exclude a group of humans from human rights, therefore – such as unborn children – we have to say one of two things. Either some human beings really are excluded from human rights, or unborn human beings are not really human beings.

Take the first option. Saying that some human beings are excluded from human rights is a daring claim – we have seen that before. But that is not to say it is false. The problem is that any basis for denying human rights to some human beings inevitably has unwelcome – or even horrifying – implications for the equality of other human beings. Consider the standard reason for saying that embryos and foetuses are not equal: that they do not have advanced cognitive capacities. But – as many supporters and opponents of abortion have noted – neither do newborn babies or people with certain disabilities. Hence some modern countries, most notably the Netherlands, have followed the Graeco-Roman precedent of euthanising some infants and people with disabilities. If we say that advanced cognitive capacities are needed to be a ‘person’, infants and many people with disabilities are not persons and can, presumably, be killed if there is sufficient benefit to society. But that’s not the only problem: if more advanced cognitive capacities are the basis of human value, it is hard to see why people with even more advanced cognitive capacities are not more valuable still. Einstein’s cognitive abilities far exceeded those of the average human being. Why should others be considered equal in value and rights to Einstein? No convincing explanation has ever been provided. Hence, to exclude some human beings because they lack advanced cognitive capacities leads both to the conclusion that it is permissible to kill many other less cognitively sophisticated human beings, and to a more general rejection of human equality even among cognitively mature adults.

Maybe you want to say that humans are persons because they have some minimal cognitive capacities – for example, being sentient (a minimal level of conscious awareness). But this has its own implausible implications: it suggests that any conscious animal – perhaps even an insect – is morally on a par with a mature human being. This is extremely implausible. But even if it were true, it would lead to a far more restrictive abortion law than in many Western countries. There is no good reason to doubt that foetuses can feel pain at just 12 weeks’ gestational age (10 weeks after fertilisation). And sentience short of pain sensation may well be possible significantly before this stage. Brain waves are detectable from just 6-7 weeks after fertilisation. By contrast, abortion is legal up to 12-14 weeks in most European countries, 24 weeks in the UK, and viability (21-24 weeks) or birth in the US and Canada (along with China, North Korea, and Vietnam).

The reality is that there is nothing that all of us hold in common except that we are all human beings. We have different skin colours, hair colours, heights, physical abilities, mental abilities, and so on. If our value, rights and equality depend on something other than this, then some humans will inevitably be left out. The pro-life view simply says that this is unacceptable: the human family is inclusive, equal, and infinitely valuable. To exclude some human beings on the grounds that they are less developed or less capable is the definition of discrimination, inequality, and injustice. It is either discrimination on the grounds of age or on the grounds of ability – neither are acceptable in a modern, progressive world that values all humans equally.

The other way to escape a pro-life conclusion is to deny that human embryos and foetuses are human beings. But this is to deny what appears to be a basic scientific fact. We are not saying that human embryos and foetuses are potential human beings. They are human beings, usually with the potential to experience significant goods in future. Nor are we saying that they are merely human; that is true, but is not enough to be a person, since skin cells are human.

The claim is, instead, that human embryos and foetuses are human beings, that is to say, members of our species, Homo sapiens. They are individual human organisms – dependent, but still individual. They (usually) have their own genetic constitution and their own future. They have all they need to develop into a mature human being, other than nutrition and a normal environment. They need these latter two – but so do infants and toddlers, who will also die without nutrition, oxygen, or the care of others.

Bear in mind that no religious scriptures talk about fertilisation; fertilisation was only discovered in recent centuries. So the idea that a new human organism originates at conception is not grounded in religious tradition. On the contrary, it was a scientific discovery in the late 19^th century. It was precisely these scientific developments in the 19^th century which led to laws prohibiting abortion during this period – and these laws were promoted first and foremost by the medical profession (see Jones and Keown).

That a human organism is created at fertilisation has remained a scientific fact ever since. It is taken for granted in countless works of embryology. A recent survey of 5 and a half thousand biologists from around the world found that 95% affirmed the view that a human organism is created at fertilisation, with the large majority of explicitly ‘very pro-choice’ biologists affirming this view. When people say that they are not human beings, they are more likely making the claim that they are not persons. That they are human beings is not seriously contested from a biological perspective (and 81% of laypeople surveyed in the same paper said that biologists are the experts on ‘when life begins’, so the biological perspective is clearly what most people have in mind when they talk about the beginning of life. As Ann Furedi, former CEO of the UK’s leading abortion provider, put it:

‘We can accept that the embryo is a living thing in the fact that it has a beating heart, that it has its own genetic system within it. It’s clearly human in the sense that it’s not a gerbil, and we can recognize that it is human life … The point is not when does human life begin, but when does it really begin to matter?’

Hence, if embryos and foetuses are human beings (a biological fact), and if all human beings are persons, equal before the law, the pro-life conclusion is inescapable. This is the logic which leads pro-lifers to hold that the life of human embryos and foetuses must be protected. It is not based on the idea of ‘potential human being’, or on religious dogma. It is a straightforward implication of a biological fact combined with a widely held and plausible view about human equality. If this view is correct, then all human beings – including those at the very beginning of development – deserve the same legal protection, and it should not be legal to end any human’s life except in extreme circumstances (e.g. in self defence). This would make the overwhelming majority of abortions impermissible, both morally and legally. To reject this conclusion, one of the premises must be rejected, or it must be argued that the circumstances are, indeed, extreme.

It has famously been said that ‘facts don’t care about your feelings’. This is true and important – the pro-life argument works regardless of how offensive it might be. But while facts don’t care about your feelings, good, compassionate people should. It is one thing to say that abortion violates a human being’s right to life in the abstract. It is another thing to say it to a survivor of a horrific sexual crime who is distraught at becoming pregnant from it. It may be true – but it is not sufficient as a compassionate response to women in desperate situations. Sometimes doing the right thing requires considerable sacrifice or heroism, and women who have been failed – by men, by a system, by their parents, or otherwise – deserve both compassion and support when being encouraged to do so. And they deserve good answers to their questions.

This brings us back to the question of the wellbeing of women. If pro-lifers claims about the embryo or foetus are correct, then every case of voluntary abortion seriously harms a woman in at least two ways: it ends the life of her child, and implicates her in something seriously wrong. Pro-lifers often claim that justice involves restoration of relationship, not just any resolution of a problem. They also often claim that pitting mothers against their children harms both. They often claim that it is impossible to harm a child without at the same time harming their mother, because that intimate connection is just part of being a parent.

Maybe you don’t believe all these things – but they are certainly plausible, if embryos and foetuses really can meaningfully be called ‘children’ or ‘offspring’ (of course, ‘offspring’ is the literal translation of the Latin ‘fetus’). What almost everyone can agree on is that abortion is, in itself, a bad thing that we would be better without, even if it is a necessary solution to a bigger problem still.

The pro-life view says that women deserve better than abortion, and that even aside from the inherent harm in losing a child or in being involved in injustice, abortion is, on the whole, harmful to women in other, empirically identifiable ways. In other words, it rejects the whole framing of the debate as a battle of the woman’s interests against those of the child. Rather, it says that we can and should help both together. Abortion is worse for the child, but is also worse for the mother and for society. We can do better, because women deserve better.

There is, of course, much more that needs to be said about the relationship between abortion and women’s wellbeing, on an individual level and on a societal level. I’ll try to do some of that in this Q&A, though many volumes have been written on it. As I say, this isn’t intended to be comprehensive – all I am offering is a starting point for better, more sincere, more evidence-based conversations about a fraught and challenging topic, which for so many people is far, far more than a theoretical debate. Please do get in touch with me if you think I have been unfair, or could phrase something more compassionately. And please forgive me if I offend by carelessness or insensitivity at any point. Thank you for your forgiveness and patience in advance.

“Being pro-life is just a religious view”

“Religious views shouldn’t be imposed on others”

Does Christianity prohibit abortion?

Does Judaism prohibit abortion?

Does Islam prohibit abortion?

Does Hinduism prohibit abortion?

Does Sikhism prohibit abortion?

Does Buddhism prohibit abortion?

Do any Biblical passages support abortion?

“Being pro-life is just a religious view”

As a straightforward empirical question, this is obviously false. US polling suggests 23% of religiously unaffiliated Americans still think that abortion should be illegal in all or most cases – a minority, but a significant one. This is actually a higher proportion than for Jews and Buddhists in the US. And of course, many more will think that abortion is wrong but should be legal, and that abortion should sometimes be illegal. But are these just formerly religious people who have accidentally held onto their religious beliefs, or might they have a non-religious basis for their beliefs?

I hope to have shown by this point that there are reasons for opposing abortion which are not based on religious premises – most of the arguments, in fact (see ‘Why pro-life?’ and ‘Are there other arguments for the pro-life position?’). Fortunately, killing is widely held to be wrong by religious and non-religious people alike. So the question is: is a foetus the kind of thing that it is wrong to kill? It is clear that there are reasons for answering ‘yes’ which don’t rely on any religious premises (see the previously mentioned posts).

The traditional secular answer is that killing any living human being is wrong. And this is exactly why the prohibitions on abortion in the 19^th century were driven primarily by doctors (see Jones and Keown), based on recent embryological developments. The Bible, of course, does not mention fertilisation – it was not even known about when the Bible was written. In light of the scientific developments in the 19^th century, and their relative absence in Biblical times, it is difficult to see how ‘life begins at fertilisation’ could be a fundamentally religious conviction. In fact, the historical evidence is clear that churches began to adopt this view precisely because science had demonstrated it. And doctors adopted it at the same time too, regardless of their religious convictions.

The Hippocratic Oath forbade abortion, though likely primarily out of concern for the woman, for whom abortion would be extremely dangerous. But in the wake of the Second World War, concern for human life from conception was evident among doctors regardless of religion: in 1947 the British Medical Association, in a statement on war crimes, maintained that ‘the spirit of the Hippocratic Oath cannot change and can be reaffirmed by the profession. It enjoins… The duty of curing, the greatest crime being co-operation in the destruction of life by murder, suicide and abortion.’ The next year, the World Medical Association’s Declaration of Geneva vowed to ‘maintain the utmost respect for human life from the time of conception’. In 1966, the year before abortion was legalised in the UK, and by which time church attendance was a small minority of the UK population, the Royal College of Obstetricians and Gynaecologists published a report unanimously approved by their Council. This vehemently opposed the legalisation of abortion, and decisively disproved false claims that many women were dying from illegal abortions, and that these women would be saved by legalising abortion. Secular medicine has always been a key driving force for the pro-life view, especially since the embryological developments of recent centuries. It is clear that one need not be religious to be pro-life.

For my own part, my religious beliefs and my beliefs on abortion came entirely independently. The UK church is for the most part either silent or pro-choice, and I was not raised in a pro-life household or church. I became convinced of the pro-life view by my experience at medical school, understanding the arguments, seeing the reality of life in the womb, seeing the reality of abortion, and understanding the impact of abortion on women.

“Religious views should not be imposed on others”

As I have suggested in the previous post, the pro-life view is not necessarily a religious view. But of course, for many people, it is grounded in certain religious beliefs. This raises two questions: are they accurate interpretations of those religious traditions, and should those views have an impact on public policy?

Although religious scriptures or traditions do not talk about fertilisation (before recent times), they do talk about life prior to birth, generally affirming its value, and the wrongness of taking that life. They sometimes talk about this life being valuable from ‘conception’ – the beginning of that life. So although they do not scientifically identify the beginning of life, they do often say that taking that life is wrong from the moment it has begun – and science has now shown when it begins. In that sense, even those who claim a religious view for their pro-life belief are still basing their views mostly on a scientific discovery – the beginning of life at fertilisation.

But suppose it were primarily or entirely a religious conviction. Should this matter? Well, it clearly at least matters for people with those religious beliefs. The large majority of the global population – perhaps a large proportion of people reading this – claim some sort of mainstream religious faith. For those millions – indeed, billions – of people, religious arguments will have some force. It would be unreasonable and exclusionary to assume that their fundamental convictions should be completely ignored, and that those convictions could never affect their moral views or lives.

It also matters because even non-religious people cannot simply assume that they are right, and that there is no chance they are wrong. If the permissibility of abortion depends on religions being false, that adds a considerable burden of proof to the defender of abortion. Are they entitled to make that assumption without a good argument? I doubt it. If Christianity, for example, entails the pro-life position, and there is a reasonable chance Christianity is true, then there is (logically) a reasonable chance that the pro-life position is true. If there are no good arguments against Christianity, then on what basis can its falsehood be assumed when coming to moral judgments?

Of course, the bigger question here is not whether religion should affect some people’s moral views, but whether it should affect public policy. Should religious views affect the lives of others? This is where some people become very nervous – isn’t that essentially a theocracy?

I think we can have a more nuanced, mature position than this. In a pluralist society, especially a pluralist democracy, everyone has a say – that is the whole point. Everyone will have basic foundational worldviews which impact their moral views. Some secular people will have an atheistic worldview where morality is based on autonomy and self-fulfilment. Other secular people will have an atheistic worldview where morality is based on flourishing relationships. Others will be agnostic, or have eclectic religious views, and so on. No one comes from an entirely neutral, uncontroversial worldview. Yet all our views must have some weight in a pluralistic democracy, and we must have some laws.

But why should secular people be able to force their views about the importance of, say, autonomy or self-fulfilment, on society (by creating legal systems based on these ideals)? Or their views on flourishing relationships? These are just as controversial, and non-neutral. The reason is presumably that, in a democracy, every view counts – complete neutrality is impossible (even a society with no laws at all would clearly be biased towards anarchists). But then the views of religious people count as well. So to exclude religious views from having any impact on public policy is essentially to bias public policy towards non-religious people, and this is wrong. In many countries, this would exclude the overwhelming majority of people from political participation.

Another reason to include religious considerations in public policy is, again, because of the possibility that they are correct – and it is doubtful whether the state is entitled to simply assume that they are not. There are, of course, endless debates about how the state should respond to claims which are possible but uncertain – such as the likelihood of a future invasion. One way of doing so is to make certain concessions to religious beliefs in proportion with the likelihood that that belief is true. This is of course not easy when it comes to religion – where there is considerable disagreement about how probable religious claims are. But to give up straight away and make no concessions at all does not seem a proportionate response either – and again, biases society towards an atheistic vision. In the same way that no one can simply assume without argument that religions are all false, and the large majority of the world is mistaken, nor can a state rationally do so.

A final reason to include religious considerations in public policy is because some of them have been shown to have considerable merit, morally. Indeed, arguably, in many ways, secularists want to retain certain Judaeo-Christian moral claims in public policy. For example, the prohibition on infanticide is a distinctly Christian innovation. But no one thinks we should abandon that prohibition because it has religious roots – even when leading secular bioethicists argue that we should abandon it. Likewise, Christianity has largely been responsible for modern conceptions of human equality and human rights (see Moyn, Spencer, Dickson, and especially Holland). If we had to abandon Christian premises for our public policy, we would likely end up discarding the prohibition on infanticide, and probably far more besides.

Does Christianity prohibit abortion?

See my handout.

Does Judaism prohibit abortion?

See my handout, along with helpful summaries here and here.

Does Islam prohibit abortion?

Although there is some disagreement between Islamic schools regarding the details on abortion, there is broad agreement on the general principles. These are that abortion is completely impermissible after ensoulment (except if the mother’s life is at risk), and permissible only in exceptional circumstances prior to ensoulment There is slight disagreement about what constitutes exceptional circumstances – but it is clear that even before ensoulment abortion is by default impermissible and these exceptional circumstances are rare.

Likewise, there is some disagreement on when ensoulment occurs: some say 40 days, some say 120 days. Others argue that these estimates were based on the science of the time, so that the correct modern interpretation is to follow the science and assume ensoulment at conception.

Hence, although Islam has traditionally not been opposed to all abortion, it is clearly opposed to the overwhelming majority of abortions. A helpful overview is given in the Journal of the British Islamic Medical Association.

Does Hinduism prohibit abortion?

Hinduism generally regards abortion as being impermissible except where the mother’s life is at risk. A helpful overview is available here.

Does Sikhism prohibit abortion?

Sikhism generally regards abortion as being impermissible and defines life as beginning at conception. A helpful overview is available here.

Does Buddhism prohibit abortion?

Buddhism appears to treat abortion on a case-by-case basis, but in general abortion is viewed negatively. The Dalai Lama has said, for example, that ‘Of course, abortion, from a Buddhist viewpoint, is an act of killing and is negative, generally speaking. But it depends on the circumstances. If the unborn child will be retarded or if the birth will create serious problems for the parent, these are cases where there can be an exception. I think abortion should be approved or disapproved according to each circumstance.’

The first precept of Buddhism is not to kill in general. It is somewhat difficult to reconcile this view with permitting abortion in certain circumstances (except where the mother’s life is at risk). Either way, it is clear that traditional Buddhist teaching is generally against abortion. There is a helpful overview here.

Do any Biblical passages support abortion?

It is sometimes claimed that some Biblical passages support abortion by supporting a lower moral status for the foetus. Those passages include Genesis 2:7; Exodus 21; and Numbers 5.

I respond in full to these claims in my paper published in Christian Bioethics, ‘Why Biblical arguments for abortion fail’, available with my other academic papers here: https://calumsblog.com/academic-papers/

The effect of abortion on women

How common is coercion?

Are abortion providers linked to eugenics?

The effect of abortion on women

The pro-life position says that both lives matter. This is a crucially important point. Pro-lifers are often misinterpreted as saying that the baby matters more. This is not the pro-life position. In fact, it directly contradicts the pro-life position, which says that all human beings are equal. The reason the child’s life takes precedence over the mother’s choice is because the right to life is the most fundamental right. This can be seen by the fact that pro-lifers almost always make an exception for the mother’s life: where another life is at stake, pro-lifers typically believe the mother has the right to defend herself against a lethal threat by delivering her baby prematurely.

It would be odd if the pro-life position were inherently anti-women, because in many countries, women are in fact more pro-life than men. Almost all women support at least some restrictions on abortion; it would be extremely strange if it turned out this meant that almost all women had a vicious kind of misogyny.

Pro-lifers have typically held that motherhood is a profound relationship. They have often said it is an inherent part of being a mother that what harms her child usually harms the mother. To most mothers, this also seems like common sense. Pro-lifers have, therefore, pointed to a variety of ways in which abortion harms women – much as many of the early feminists saw abortion as exploitative and anti-women. As social science and psychiatry have been revolutionised in the latter 20^th century, more and more evidence has come to light about the ways in which abortion has not been as liberating to women as is often suggested. As well as evidence suggesting that in very general terms, women’s happiness has decreased since the 1970s (in absolute terms and relative to men), despite enormous material advances made by women in that time, there is specific evidence on the many ways in which abortion has harmed them.

Since there are a huge variety of ways in which abortion negatively affects women, some of this material is covered in other sections:

1. ‘Can men speak about abortion?’ (Excluding men from the conversation puts burdens of unwanted pregnancy on women alone)
2. ‘Abortion and mental health’ (Abortion is bad for women’s mental health across a variety of mental disorders, including alcohol and substance abuse)
3. ‘Is sex-selective abortion a serious problem?’ (Sex-selective abortion is almost always against girls and leads to further problems like human trafficking)
4. ‘What about women’s choice?’ (Abortion legalisation can in some ways deprive women of choice)
5. ‘Physical consequences of abortion’ (Abortion has damaging physical complications and increased rates of STD transmission via legalisation – STDs in turn causing infertility, cervical cancer and various other problems, even death)
6. ‘Abortion and maternal mortality’ (Ways in which abortion can increase mortality rates)
7. ‘Is unsafe abortion economically burdensome?’ (Economic costs to women of abortion legalisation)
8. ‘Does restricting abortion lead to more unwanted births?’ (Abortion legalisation causes more unwanted pregnancies)
9. ‘Unwanted children lead to educational and career problems’ (Abortion legalisation can lead to economic difficulties for women)
10. ‘Unwanted children lead to poverty’ (Abortion legalisation can lead to economic difficulties for women)
11. ‘Unwanted children and child abuse’ (Abortion legalisation may have led to higher rates of child abuse – and half of children are women/girls)
12. ‘Does abortion reduce crime rates?’ (Abortion legalisation may have led to higher crime rates, especially among men – which has an impact on women)

What is particularly notable is how many of these have an impact on multiple generations. We know that mental health difficulties, poverty, family breakdown and various other difficulties are often transmitted down within families, with quality of relationships and a mother’s mental health being one of the primary determinants of a child’s happiness throughout their life. Some of the harms last for life: an increase in suicidality, for example.

In this section, I will say a bit more about some of the other ways in which abortion harms women.

Abortion is an insurance option against unwanted pregnancy: it provides women with an option to end their pregnancy even if all other precautions fail. For this reason, in economic terms, it lowers the ‘cost’ of having risky sex – sex with someone with whom one would not want to raise a child. This allows sex with more different people and with less care to use effective contraception. The empirical evidence that abortion has this impact is overwhelming (see, for example, ‘Does restricting abortion lead to more unwanted births?’). In other sections I’ve talked about how this has led to increased STD transmission and unwanted pregnancies.

But the change in sexual dynamics resulting from increased abortion access has far-reaching consequences aside from unwanted pregnancies and sexually transmitted diseases. Two of the first economists to pick up on this were Nobel prize-winning economist George Akerlof and (now) US Secretary of the Treasury, Janet Yellen. They argued with Michael Katz that increased access to abortion and contraception in the early 1970s led to radical changes in sexual relationships, marriage, out-of-wedlock births, and the number of children living with only one parent. They describe how this has led to the ‘immiseration of women’ and the ‘feminization of poverty’:

“Over the last 25 years disturbing trends have occurred in the United States (and other Western countries as well). Just at the time, about 1970, that the permanent cure to poverty seemed to be on the horizon and just at the time that women had obtained the tools to control the number and the timing of their children, single motherhood and the feminization of poverty began their long and steady rise. As a result, United States poverty rates have been stubbornly constant for the last quarter century.”

Akerlof put it more candidly elsewhere:

“Today we face another problem, another type of disaster. That disaster is the failure of the family system in America, which has fallen apart not just for those who have ended up on welfare but to a significant but smaller degree for those higher in the distribution of economic and social rewards.”

The adverse consequences of single-parent families for children and for the women usually left to bear most of the burdens are substantial, widespread and well-known – as just one example, divorce is widely known to be associated with increased suicidality for both parents and children. Marriage is associated with significantly better outcomes for the partners across a wide range of other consequences. Father absence is associated with a litany of poor outcomes for children. The decline in marriage in the US has been estimated to account for half the increase in child inequality since the 1970s, and more than the increase in child poverty, with African-American children especially affected. Akerlof, Yellen and Katz describe the disproportionate negative impact these economic changes have had on women in particular. More recently, their argument has been developed by Helen Alvaré, among others. A fuller review of the economic benefits of marriage is given by Lerman and Wilcox, and this is a helpful overview of the various negative consequences of family breakdown from Princeton University.

Akerlof argued in a separate paper that these same shifts in marriage customs were primarily responsible for various other ‘social pathologies’: rising crime rates and substance abuse in particular. He argued that the delay in men marrying – in significant part due to abortion legalisation – led to an extended adolescence of men whereby they failed to take responsibility and continued in various scandalous behaviours in which single men are more likely to take part. In short, the delay and breakdown of marriage and fatherhood, two of the primary civilising factors on men, allowed men to refuse to take responsibility and continue in the various social pathologies of their youth, often exacerbated as they get older. An increase in such behaviours can reasonably be expected to have poorer consequences for everyone, and especially women, who are left to shoulder the burden of irresponsible men. Likewise, the relative paucity of marriageable men has been a bad thing for the majority of women, who want to marry and have children with a man.

It goes without saying that poorer women and children, in particular, have been the primary victims – financial and otherwise – of the family breakdown facilitated by greater access to abortion in the early 1970s (and similar times across the West). Likewise, the African-American community has been particularly affected by family breakdown and its economic and other consequences. This litany of consequences of family breakdown is not unique to the US; UK studies have confirmed the same impression, particularly its impact on inequality.

Other subsequent changes in sexual behaviour and the mating market have been documented elsewhere. Helen Alvaré points out, for example, how the resultant sexual market looks far more like a reflection of men’s preferences than of women’s in a variety of ways, including the proportion of men and women who regret sexual encounters. Hill joins Alvaré in noting how the sexual market has been bifurcated into a short-term ‘sex’ market and a long-term ‘mating’ market: while the changes in sexual behaviour suit women in the sex market, they have a far more detrimental impact on the (large) subset of women looking for a long-term partner, who are now more frequently unable to do so.

Unwanted pregnancy is often not very significant for men: they can deny it, or leave, or never even find out about it. But unwanted pregnancy – however it ends – is an enormous burden that falls disproportionately on women. Women are faced with the challenges of pregnancy and single parenthood for the rest of their lives, or the even greater psychological difficulties of having an abortion. Given that the evidence suggests women have a much stronger preference for fewer partners, commitment and stability in relationships than men, a non-committed sexual culture puts women at a considerable disadvantage compared to men.

The facilitation of early sexual debut and multiple partners by increased abortion access is also linked with a litany of negative consequences for women, including risky sexual behaviours, reduced marital satisfaction, reduced educational attainment, STDs, unwanted pregnancies, abortions, single motherhood, child and maternal poverty, and overall reduced happiness. Other authors have linked abortion more directly with sexual dissatisfaction, relationship breakdown and divorce in individual cases as well as indirectly through the culture. It is likewise difficult to believe that the recent rise in anorexia nervosa – which has the highest mortality rate of any psychiatric condition – is unrelated to these shifts in the sexual climate.

Given that relationships and mental health are the two biggest determinants of happiness, the fact that abortion has caused poorer mental health and poorer relationships is very significant – and perhaps responsible for the decrease in women’s happiness over the last few decades, despite myriad material gains.

There are other ways in which abortion has been harmful for women besides. For example, it makes it more likely that a woman will not have as many children as she wants in her lifetime. The number of women intending to have no children is well below 10% in most European countries, below 5% in most cases and close to non-existent in some. In fact, there is a ‘fertility gap’ in many Western countries; women in general have fewer children than they desire, and contrary to popular belief, women in the US were found to want more children, on average, than men in the US. Women were also more likely than men to say that children were ‘one of the most important things’ to them.

Abortion has likewise been a critical component of sex trafficking, since pregnancy and children make women taken captive as sex slaves ‘unavailable’ for ‘work’. Likewise, it is often forced upon other victims of sexual violence, in part to remove any evidence of the crime. Domestic abusers also frequently force abortion on women. A variety of studies have suggested that around 20-25% of abortions are due to pressure from others, usually a male partner but also often parents or others. In some cases, doctors or abortion providers pressure or even force women to have abortions. For more on this, see ‘How common is coercion?’ below.

In summary, there are an enormous range of ways in which abortion is harmful for women – some very direct, others far more indirect. But in light of all of these, it is no surprise at all that women are, according to the empirical data, no happier than they were 50 years ago, before all of their important and world-changing advances in society. From an empirical point of view, the evidence is relatively clear: abortion is not good for women. Hence the pro-lifer can sincerely say that both lives matter, and that women deserve better.

How common is coercion?

Coercion is very common, accounting for a significant minority of abortions. For example, in one of the most well-known studies, it was found that 25% of Norwegian women having abortions said that ‘pressure from male partner’ was a reason, and on average these women said it was ‘a great deal’ in importance. This was, as in other studies, clearly related to worse psychological outcomes. 9% were pressured by friends, 5% by mothers, 4% by fathers, 4% by siblings, and 2.5% by others. Women could select multiple options so there is probably significant overlap, but it is clear that pressure from others is very common. The authors noted that ‘male partner does not favour having a child’ (36%) could also count in addition as a softer form of pressure. They describe:

“Women in this study gave examples of what they experienced as pressure from the male partner—one man said that if the woman did not have an abortion, she would ruin his future and his whole life. Another man threatened to break up the relationship and let the woman become a single mother. Thus, lack of important social support, sympathizing with the male partner, a broken heart and fear of standing alone may be components of the reason “pressure from the male partner” to have an induced abortion.”

Pressure from friends was not trivial either: “Although only few women gave the reason “pressure from friends” for having an abortion, this reason had a surprisingly strong impact on the subsequent psychological responses.”

Other studies show similar rates of coercion. The Demographic and Health Surveys for Gabon and the Republic of Congo found that in both countries 20-25% of abortions were decided for the woman by someone else, and a survey in the UK found that 7% of women had been pushed into having an abortion. Given that around 30% of women have an abortion at some point in their life UK, and some women in the survey would not have had an abortion yet, a similar figure of 20-25% of women having abortions being coerced is evident.

Pressure from other sources is also known, for example, from parents. The pressure private abortion providers put on women to have an abortion to reach performance targets is now well-known. The CQC, for example, which regulates healthcare providers in the UK, found that at Marie Stopes:

“Staff were also concerned that the pressurised environment and linking of KPIs to performance bonuses meant that there was a culture that worked against patient choice. They talked about implants being fitted whilst the patient was sedated (at the same time as the operation) and the limited time available to discuss the choices prior to this. One staff member described it as “feeling like a hamster in a wheel” and said the word, “Cattle market” came up quite a lot.”

Notably, “Did not proceed” [with abortion] was a key performance indicator, with a target of 98-100% of women leaving with the ‘treatment’.

Former workers at Planned Parenthood have likewise spoken out about the quotas they were given for performing abortions. The Demographic and Health Surveys previously mentioned found significant numbers of women being coerced by parents and healthcare professionals.

This pressure is particularly common on women who have a child with a diagnosed disability. In cases of trisomy 13 and 18, 61% of parents who continued the pregnancy felt pressure to abort from healthcare providers – and presumably a higher percentage of those who ended up aborting. Likewise, even in the liberal democratic West, disabled women themselves are sometimes forced under doctors’ and courts’ orders to undergo an abortion against their explicit will.

Of course, this does not take into account soft or implicit pressure to have an abortion, whether through lack of informed consent, social engineering towards two-child families, economic pressures, or pervasive or pervasive maternity/pregnancy discrimination in employment (including, of course, at Planned Parenthood): within just a year of legalised abortion in Ireland, female pilots were being told to have an abortion or lose their job, for example. The other sorts of societal pressure to abort are diverse and not always overt: in one recent case a rape victim and refugee was rejected her refugee claim because her rape story was deemed uncredible on the basis that she did not have an abortion (See Prewitt’s paper for more discussion of pressure facing rape victims to abort). Lederer and Wetzel have carefully documented the central role that forced abortion plays in perpetuating sex slavery. The horrors of population control programmes in the latter 20^th century and their use of abortion are well known.

In sum, coerced abortion is not a fringe phenomenon. It is a very common phenomenon, with explicit coercion taking part in a significant minority of pregnancies, and soft/implicit pressure in many more (probably most). These problems have no doubt been exacerbated by the move towards telemedicine abortion, removing the one safeguard women had against coercion (being seen alone face-to-face), as I describe more in my chapter on telemedicine abortion.

Are abortion providers linked to eugenics?

Major abortion providers today have traditionally tried to downplay their links to eugenics and racism throughout the 20^th century. In recent years they have generally acknowledged these links: after years of knowing that Margaret Sanger, who founded Planned Parenthood, was an ally (at least) of racists and an avowed eugenicist, Planned Parenthood finally (in 2021) decided it was time to acknowledge this and that it was a problem. Likewise, with Marie Stopes International changing its name to MSI Reproductive Choices after acknowledging Marie Stopes’ eugenics and racism. Of course, brand awareness is still more important than fully disavowing a racist and eugenicist past, so the organisation still retained ‘MSI’ in its new name: we can only guess what it stands for.

Entire volumes have been written about the history of International Planned Parenthood Federation (IPPF), the Guttmacher Institute (a pro-abortion think tank ‘originally housed within the corporate structure of Planned Parenthood Federation of America’, still receiving financial support though now independent), and MSI Reproductive Choices, and their links with racism, eugenics, and coercive control of women’s reproductive choices in the name of ‘population control’. The best books on these topics are Matthew Connelly’s Fatal Misconception, Angela Franks’ Margaret Sanger’s Eugenic Legacy, and there is a small amount of helpful material in Fred Pearce’s The Coming Population Crash.

Let’s begin with the prestigious Guttmacher Institute, regularly seen as perhaps the leading think tank on reproductive health around the world, though it is openly devoted specific political ideologies relating to abortion.

The Institute describes Alan Guttmacher, its forefather, as ‘an eminent obstetrician-gynecologist, author and leader in reproductive rights who was PPFA’s president for more than a decade.’ What they don’t mention is that he was also a leading eugenicist, becoming Vice-President of the American Eugenics Society in 1958 and remaining a member until at least the mid-1960s.

To give some background on this society that Guttmacher presided over, the American Eugenics Society was founded by, among others, Madison Grant and Henry Osborn Sr – both of whom were good friends of an early Planned Parenthood Director, Lothrop Stoddard (the triumvirate set up the Save the Redwoods League together).

Henry Osborn Sr wrote the foreword for Madison Grant’s bestselling book The Passing of the Great Race, in which Grant lamented the threat posed to the superior Nordic race. The book was cited as inspiration by Karl Brandt as inspiration in the Nuremberg trials, and was referred to as ‘my Bible’ by none other than Adolf Hitler. As for Stoddard, he authored The Rising Tide of Color Against White World Supremacy and believed that social reform to reduce inequality was ‘one of the most pernicious delusions that has ever afflicted mankind’. He was rewarded within a few years by being appointed a director of the American Birth Control League (later to become PPFA). Stoddard was a member of the KKK, claiming that ‘The black man is, indeed, sharply differentiated from the other branches of mankind… The negro… has contributed virtually nothing. Left to himself, he remained a savage’. When his consultancy and membership of the KKK was revealed, he wrote a letter to Osborn Sr, complaining about the ‘radical-Jew outfit’ which had exposed him (the magazine was Hearst’s International, later to combine with Cosmopolitan).

Guttmacher was a close friend and described himself as an ‘extravagant admirer’ of Osborn Sr.’s nephew, Frederick. Frederick Osborn was perhaps the foremost eugenicist in America at the time, having described the work of Otmar von Verschuer’s work rooting out hereditary diseases as ‘the most exciting experiment that had ever been tried.’ For context, Verschuer was responsible for Germany’s forced sterilisation program in the late 1920s and in a 1944 report described Josef Mengele at Auschwitz as his assistant researcher. Verschuer was later accepted as an honorary member for life into the American Eugenics Society, alongside Guttmacher.

Guttmacher believed that when it came to abortion, ‘the quality of the parents must be taken into account’, including ‘feeblemindedness’. Rejoicing over progress in expanding abortion, Guttmacher said that ‘We’re now concerned more with the quality of population than the quantity’. Although he claimed that voluntary birth control was preferable, it may not be enough. In 1969, the major medical magazine World Medical News reported:

‘[Guttmacher] foresees the possibility that eventually coercion may become necessary, particularly in areas where the pressure is the greatest, possibly in India and China. “Each country,” he says, “will have to decide its own form of coercion, and determine when and how it should be employed. At present, the means available are compulsory sterilization and compulsory abortion. Perhaps some day a way of enforcing compulsory birth control will be feasible.’

While Planned Parenthood has begun, in 2021, to disavow the racism and eugenics of its founder, Margaret Sanger, the Guttmacher Institute, a Planned Parenthood spin-off, is still named after, and extols on its website, this gentleman. We have already talked about Lothrop Stoddard, an early director of Planned Parenthood, but what about the rest of Planned Parenthood?

PPFA and its international umbrella federation, the International Planned Parenthood Federation, both have deep historical roots in eugenics and coercive population control. Both were founded by Margaret Sanger, whose ‘harmful connections to the eugenics movement’ were finally recently acknowledged by one PPFA chapter. The chapter even recognised ‘Planned Parenthood’s contributions to historical reproductive harm within communities of color’. A couple of select quotes from Sanger:

‘No woman shall have the legal right to bear a child, and no man shall have the right to become a father, without a permit for parenthood… no permit for parenthood shall be valid for more than one birth.’

‘The campaign for birth control is not merely of eugenic value, but is practically identical in ideal with the final aims of Eugenics.’

Sanger likewise wrote, in an entire chapter on ‘The Cruelty of Charity’ that ‘Organized charity is the symptom of a malignant social disease. Those vast, complex, interrelated organizatioorganizations aiming to control and to diminish the spread of misery and destitution and all the menacing evils that spring out of this sinisterly fertile soil, are the surest sign that our civilization has bred, is breeding and perpetuating constantly increasing numbers of defectives, delinquents and dependents. My criticism, therefore, is not directed at the “failure” of philanthropy, but rather at its success.’

Guttmacher’s immediate predecessor as National Director of PPFA was William Vogt, perhaps the most prominent early writer on population control in the world. Vogt, like the eugenicists, wrote in the aftermath of the second world war, a time of heightened human rights awareness, but he warned that ‘The world is now full.’ As a result, he vehemently opposed charity and aid, particularly those efforts that aimed to save lives overseas. ‘The greatest tragedy that China could suffer at the present time is a reduction in her death rate’, he wrote in his best-selling Road to Survival. India had been previously ‘held in check’ by ‘disease, famine, and fighting’, but Vogt lamented that the British had now ruined this homeostasis by ‘building irrigation works, providing means of food storage, and importing food during periods of starvation’, while ‘the Indians went their accustomed way, breeding with the irresponsibility of codfish.’ Future aid was to be conditional on accepting strict population control, and people should be paid to be sterilised: ‘Since such a bonus would appeal primarily to the world’s shiftless, it would probably have a favorable selective influence… it would certainly be preferable to pay permanently indigent individuals, many of whom would be physically and psychologically marginal, $50 or $100 rather than support their hordes of offspring that, by both genetic and social inheritance, would tend to perpetuate the fecklessness.’ On Puerto Rico, Vogt wrote: ‘Puerto Rico is poor in resources and almost without power—except the power to reproduce recklessly and irresponsibly.’ Sanger subsequently helped launch the infamous Puerto Rico contraceptive trials, in which Puerto Rican women were misinformed and experimented upon with dangerously high doses of contraceptives, leaving several dead. Vogt was rewarded for his Road to Survival by being appointed national director of Planned Parenthood within a few years.

In 1952, the Rockefeller and Ford Foundations helped to set up the Population Council, run by Frederick Osborn, the fan of Verschuer’s work in Nazi Germany. When Guttmacher was about to take the Presidency of Planned Parenthood, it was a difficult choice for him between Planned Parenthood and a senior position at the Population Council.

Notes from the initial meetings of the Population Council were recently uncovered by Columbia University researcher Matthew Connell. At this meeting, Vogt – at the time Director of Planned Parenthood – argued vehemently for withholding industrial development from poor countries like India, He was supported by another Osborn, Fairfield. Another pioneer at the meeting, Kingsley Davis, had elsewhere maintained that food aid was worse than useless, and opposed migration to the US of ‘tens of thousands of impoverished, illiterate, superstitious, non-English-speaking, and in many cases, diseased, new citizens.’ Vogt himself also added that there was no case for the US subsidising ‘the unchecked spawning of India and other countries by purchasing their goods’.

Fred Pearce, award-winning environmental consultant at the New Scientist, sums up:

‘From the start, the IPPF was an alliance of the old eugenics lobby and a new generation of women more concerned with reproductive rights. Other original board members now largely airbrushed from the story include its first president, the controversial eugenicist Margaret Sanger, and a future chairman, Carlos Blacker. An Eton-educated psychiatrist and acolyte of Julian Huxley, Blacker had for more than two decades been secretary of the British Eugenics Society—which hosted the IPPF in its London offices.’

Blacker himself did not need to be as enthusiastic about forced sterilisation, since in his view, ‘defectives, being for the most part readily suggestible, should in most cases be easily persuaded’. He left his role at the Eugenics Society to be the Chairman at IPPF. More politically astute, Blacker favoured ‘crypto-eugenics’, which he described as seeking ‘to fulfil the aims of eugenics without disclosing what you are really aiming at and without mentioning the word.’ He credited Frederick Osborn with the idea, and Connelly describes how this was how the Eugenics Society understood its early funding for IPPF.

IPPF continued to be involved in population control scandals globally long after World War II. They were the biggest funders of sterilization under Indira Gandhi, increasing their funding along with UNFPA and the Swedish government’s international aid agency (SIDA) after Gandhi’s National Population Policy was announced. The policy included the clause that ‘Where [an Indian] state legislature, in the exercise of its own powers, decides that the time is right and it is necessary to pass legislation for compulsory sterilization, it may do so.’ Swedish media later dubbed their own government’s involvement as ‘SIDA’s Watergate’.

Connelly likewise describes IPPF’s role in setting up the China Family Planning Association just after the one-child policy was introduced in 1979. In 1980, an IPPF information officer warned, ‘in the not-too-distant future all this will blow up into a major Press story as it contains all the ingredients for sensationalism—Communism, forced family planning, murder of viable fetuses, parallels with India, etc. When it does blow up, it is going to be very difficult to defend.’ By 1981, IPPF had helped to set up the Chinese Family Planning Association, to this day a member association of IPPF.

While PPFA, IPPF and the Guttmacher Institute are now adamant that they support only voluntary family planning, their history tells a very different story. In any case, different scandals have emerged more recently. A recent audio clip released appears to demonstrate PPFA accepting a donation specifically to abort black children, for example.

The Guttmacher Institute is now mostly funded by organisations other than Planned Parenthood. Their donors include SIDA, who helped fund Indira Gandhi’s forced sterilization campaign, the Ford Foundation, who funded the early eugenic Population Council and internally floated the idea of annual contraceptive aerial mist sprayed over India, and Marie Stopes International, which has been sanctioned by multiple African countries and the UK for illegal activity, including (in the UK) performing abortions on children and disabled women without taking legitimate consent. Marie Stopes herself was also a devout eugenicist who advocated for ‘half-castes’ to be sterilised at birth and lobbied for Bills to ‘ensure the sterility of the hopelessly rotten and racially diseased’.

The Guttmacher Institute is also funded by the Brush Foundation, originally the Charles F. Brush Foundation for the Betterment of the Human Race, a foundation established specifically for ‘furtherance of research in the field of eugenics and in the regulation of the increase in population’.

Notably, they are also funded by the UK government, recently implicated in a scandal after the Independent Commission for Aid Impact found that it did not pursue ‘the strengthening of health systems to provide quality maternal care with the same intensity as it did for family planning’. That is to say, ‘family planning’ is still taking priority over saving mothers’ lives. As throughout the history of Guttmacher and his associates, genuine aid is being compromised for the sake of population control.

This is not to say that everything the Guttmacher Institute, Planned Parenthood and MSI publish is false. At times, they have published informative research. But it is important to be aware that these are not neutral healthcare and research organisations: they are first and foremost advocates for legal abortion with significant historical ties to eugenic population control and racism which cannot be downplayed or whitewashed.

Does restricting abortion lead to more unwanted births?

Who will adopt all the extra children?

“Pro-lifers are hypocrites and pro-birthers”

“Unwanted children lead to educational and career problems“

“Unwanted children lead to poverty”

Unwanted children and child abuse

Does abortion reduce crime rates?

Does restricting abortion lead to more unwanted births?

This question is important for three main reasons: it is alleged that unwanted births harm those children (by being unwanted and having lives not worth living), that they harm the mothers (physically, economically, educationally, economically, and so on), and that they harm society (by increasing the welfare cost of raising children, and so on).

I will respond to each of those specific allegations elsewhere, but since all of these claims depend in part on the seemingly obvious claim that restricting abortion leads to more unwanted births, I thought this was worth a question in itself.

The reason is that the answer is not at all obvious. It is often assumed that every abortion – 200,000 a year in the UK, many more in other countries – would instead result in a child. But in fact that is not what the empirical evidence shows, as summarised best by Philip Levine’s Princeton University Press volume on the economics of sex. While the evidence that pro-life laws reduce abortions is widely known within the relevant circles of academia (admittedly relatively small circles), the evidence concerning the impact of these laws on sexual behaviour and birth rates is far less widely known.

It turns out that there is a lot of evidence showing that laws protecting women and children lead to changes in sexual behaviour so as to make people more careful – having sex with fewer partners, using contraception more often, or better contraception, and so on. For example, in Nepal the expansion of abortion services led to a reduction in the use of modern contraception, while in Russia a significant minority of women explicitly cited the availability of abortion as a reason for not using contraception. Klick and Stratmann have repeatedly shown across multiple samples and countries that abortion legalisation leads to an increase in risky sex.

It can therefore be expected that fewer unwanted pregnancies will occur in the first place when pro-life laws are in place. This is a good thing for everyone, especially women who disproportionately suffer the burdens of unwanted pregnancies. Since many unwanted pregnancies end in births, there is a reason to think that fewer unwanted pregnancies means fewer births, other things being equal.

Whether pro-life laws increase unwanted births is, therefore, a question that can only be settled empirically. In fact, the empirical evidence clearly shows that moderate restrictions on abortion, while reducing the abortion rate, do not increase the birth rate at all. Complete bans on abortion do appear to increase the birth rate, but only by a relatively small amount, and the effect is often temporary – see, for example, Romania’s 1967 ban on abortion, which, even with a joint ban on contraception at the same time, led to only a brief spike in birth rates for a couple of years before birth rates gradually returned back to baseline rates. Neither Chile nor Poland, the countries to have banned abortion completely in recent times, saw significant increases in birth rates following their bans on abortion.

Arguments suggesting that restricting abortion lead to many unwanted children therefore rest on a pillar which is generally empirically false – and have other problems in addition (see the questions on those arguments). In fact, legalisation of abortion certainly leads to more unwanted pregnancies, which burden women disproportionately, and may even lead to more unwanted children (by increasing unwanted pregnancies and decreasing the ‘acceptability’ of pregnancy).

Who will adopt all the extra children?

It is often claimed that if women and children are protected by pro-life laws, there will be a huge number of children available for adoption, since there are already so many children in foster care. This is sometimes linked with the ‘hypocrisy’ question: why haven’t you adopted all those children?

I’ll say a lot more about the hypocrisy under ‘Pro-lifers hypocrites and pro-birthers’. But it’s worth saying one thing in response to this specific allegation: namely, that opposing killing a certain group of human beings doesn’t entail a duty to provide for all of them (though of course society has a duty to do what they reasonably can to provide for the vulnerable). During the migrant crisis in Europe a few years ago, a huge number of people protested the conditions to which they were subject, and advocated (rightly) for their wellbeing. Almost none of the people who did so actually took a migrant in to their own homes. This was not hypocritical. It would be even less hypocritical to oppose the killing of those migrants while at the same time not providing for them. This is not at all to say the affluent and powerful (which includes the average person in the West) have no obligations to ensure the basic needs of vulnerable human beings are met – as a welfarist and a Christian I think both the government and private individuals have a duty to do so.

I certainly encourage adoption and think that some people have a duty to adopt. There are certainly some children very much in need of parents. It is also a profoundly important alternative to abortion for those women who are not in a position to raise a child. But that is clearly a distinct (though related) issue from whether it should be legal to end their lives.

And there are a number of other reasons why this question misses the mark:

First, as shown in ‘Does restricting abortion lead to more unwanted children?’, abortion restrictions do not typically result in higher birth rates – only when abortion is fully restricted, and even then only by a relatively small amount and for a temporary period. Instead, people adapt to the laws and are more careful about whom they have sex with and use of contraception. This is better for everyone: it prevents many unwanted pregnancies, which overwhelmingly burden women. So there is no empirical evidence there would be large numbers of unwanted children being born.

Second, the large majority of women denied abortions choose to raise their children themselves. In the Turnaway study, of the women denied abortions who gave birth, 91% raised the child themselves (and of those, 98% were glad they were refused abortion by the child’s 5^th birthday). Interestingly, choosing adoption was not associated with age, race or poverty status, and women choosing adoption were actually more likely to have completed high school than women raising the baby themselves, though less likely to be in employment. For these first two reasons, the number of children available for adoption would be very, very small.

Third, by contrast, the number of willing parents vastly exceeds the number of newborn babies available for adoption. Ann Furedi, former CEO of BPAS, the UK’s leading abortion provider, notes that while there are over 200,000 abortions in England and Wales each year, there are only 200 newborn babies placed for adoption. By contrast, although it is difficult to find estimates, there are thought to be around 1-2 million parents in America waiting to adopt, and there are already 140,000 adoptions in the US each year (adjusting for population, that would make about 200,000-400,000 parents waiting to adopt in the UK, far exceeding the available 200 a year). In the US, the waiting list to adopt a child with Down Syndrome is typically around 1-2 years, but in some cases up to 5. While children with Down Syndrome are deeply treasured and equally valuable to other children, they are not always seen that way by prospective parents, hence there being a 90% abortion rate for children with Down Syndrome in many European countries. Disabled and non-disabled children alike are in short supply. Hence it is pretty clear that regardless of the exact numbers, the number of parents wanting to adopt far exceeds the number of extra children who would be placed for adoption if abortion were to be prohibited.

So why are there so many children in care? The reason is that most children in care are from wanted pregnancies and were taken from their parents after an unforeseen or unwanted family breakdown – abortion would have made no difference in these cases. Indeed, most children in care are hoped to be reunited with their birth families after some time and are never even placed for adoption. In the UK, out of 80,000 children in care, only 6,000 are available for adoption. The reasons not all of those are adopted are far more complex than a lack of prospective parents. Even if there were a lack of parents for older children in care, however, there has never been a lack of parents willing to adopt a newborn baby, which is the relevant consideration in the case of abortion. Hence, the short answer to the original question is: the many thousands (or millions) of parents who are already seeking to adopt a baby and unable to do so because there are so few available.

“Pro-lifers are hypocrites and pro-birthers”

As I write this, I am (to my shame) in a Twitter conversation with someone claiming that pro-lifers are inconsistent for opposing abortion while not opposing war, the death penalty, and guns, and while opposing parental leave, welfare, universal healthcare, and so on. Let me say clearly that it is only an inhumane society which leaves women to carry the burdens of a crisis pregnancy alone. I believe that governments should step in to ensure as much as possible that no woman ever feels she needs to have an abortion. Fathers have even more of a duty to ensure this, and it is a disgrace that so many men have been permitted throughout history to walk away from these responsibilities, leaving the woman to deal with them alone.

But there is a bit of an irony in the allegation that pro-lifers are myopic, since it implicitly assumes that all (or even most) pro-lifers are American Republicans who agree with that party platform. As I’ll show, the association between those issues is largely an historical accident unique to the American context and has little to do with the global pro-life movement generally. Nevertheless, as an English pro-lifer who is pro-welfare, anti-capital punishment, pro-universal healthcare, pacifist, and so on, it is surprising how much I am criticised for being short-sighted and ignorant by pro-choicers who assume that I must be an American Republican who opposes all these views. The world is far bigger than America, and in most countries there is little to no association between these views. In the UK, for example, Labour voters are just as likely to be pro-life as Conservative voters.

Of course, the same (mutatis mutandis) was true in the US too until fairly recently in history, as chronicled by Daniel Williams in his Oxford University Press book on the history of the pro-life movement in the US. Until the 1970s, the pro-life movement was largely based among pro-life Catholic Democrats who supported Roosevelt’s New Deal massively expanding welfare. In the 1960s and 1970s, both parties had very mixed records on abortion, and it wasn’t until the later 1970s that Evangelical Republicans began to be more heavily involved in the pro-life movement. It wasn’t until the Democrats began to shift firmly towards the pro-choice side that many pro-lifers felt they had no choice but to reluctantly move to the Republican Party, despite deep disagreements on various issues. This has only increased in recent times as the Democrats have purged the last few remaining pro-lifers from the party. For my own part, as someone who knows a huge number of American pro-lifers, there is an incredible desperation for a third party – or even just a place for pro-lifers in the Democrat Party, to give a real choice. The marriage of pro-life issues and the rest of the Republican platform was never intentional, and to this day is hardly a consensus. There is barely even a hint of it anywhere outside of the US.

And in fairness to the Republicans, they are not always as bad as their reputation. In recent weeks, a pro-choice Democrat State Representative from Oklahoma came out with the perfect ‘gotcha!’ to Republican pro-lifers: ‘This week I filed HB3129, which codifies that a father’s financial responsibility to his baby & their mom begins at conception. If Oklahoma is going to restrict a woman’s right to choose, we sure better make sure the man involved can’t just walk away from his responsibility.’

The problem? Pro-lifers unanimously supported it. In fact, the only people who rejected the bill were the Representative’s own team, who castigated him and forced him to backtrack, saying that he ‘obviously’ isn’t ‘moving forward with this bill as written’ and would ‘go back to the drawing board’. More embarrassing still, the Republican Party had literally already proposed essentially this bill at a federal level two years earlier. At that time too, it was met with unanimous applause from Republican pro-lifers, and not a whiff of support from pro-choice Democrats.

Clearly there are a few other issues, however. Are these positions hypocritical? And are pro-lifers hypocritical for not doing more practically for women experiencing crisis pregnancies?

Let’s take the first question. Of course, not all pro-lifers even in America support these positions – they often just take the package deal as the least bad of two realistic options. That’s not hypocritical – it’s just politics. What about those pro-lifers who do support those positions? Again, although I personally do not, it is hard to believe that they are hypocritical. Being pro-life in the context of abortion means that you oppose the intentional killing of innocent human beings. That is perfectly consistent with supporting, for example, the killing of guilty people in capital punishment, however wrong the latter position might be. Likewise, the morality of killing is completely distinct from (though related to) the morality of saving people through healthcare, and so on. In other issues, full-blooded Republican pro-lifers could be mistaken without being hypocritical. They might think that universal healthcare makes healthcare worse and lead to more deaths, for example. However wrong that position might be, it is not hypocritical. Thinking that welfare is best given privately than by the state might be wrong, but it is not hypocritical. Likewise, given the evidence that welfare can increase the abortion rate in pro-choice states (see ‘Does welfare reduce abortion?’), it is easy to see how opposing welfare but supporting pro-life laws could be consistent, however wrong.

What about the work that individual pro-lifers do? In fact, they do a great deal more than they are given credit for. Laura Hussey has documented in comprehensive detail the work that pro-lifers do in practice to support women in crisis (and non-crisis) pregnancies – and afterwards. She notes that there are nearly three thousand crisis pregnancy centres across the US. Each of these has an average of 40 volunteers contributing an average of 5 hours every week. This is on top of an average of 5.7 paid staff, only a tiny proportion of whose funding comes from the state. The overwhelming majority of centres either provide or refer women for a wide range of goods and services, ranging from baby care products to furniture, food, housing, childcare, medical care, and even cash. This work is not just about discouraging women from abortion: in fact, the majority of women helped by these centres were never considering abortion to begin with, while 79% of centres continue offering help after the baby’s first birthday, and 20% continue support even after the child’s 5^th birthday. Indeed, some pro-life pregnancy centres have even been criticised for not doing enough to discourage abortion! As Hussey shows, the empirical research available shows very high client satisfaction from these centres. And this work doesn’t include the many other kinds of pro-life pregnancy help, such as the myriad adoption centres or maternity homes across the US.

The scope of this charitable work is enormous. And it far surpasses the political pro-life work which goes on in the US – in direct opposition to common perception. As Munson puts it, ‘more individuals are involved in volunteering more time in the individual outreach stream than in any other [pro-life] movement activity. The number of organizations involved in individual outreach is greater than the number involved in all the other streams combined’.

Despite all this, such centres are constantly maligned in the media, especially by abortion advocates. Indeed, there continue to be a variety of attempts to have them defunded or shut down, either directly or by forcing them to refer to abortion, which could clearly contradict their fundamental values. Likewise, many Western countries are trying to ban people from offering support outside abortion clinics, which is known to be needed by some women, and many Christian adoption agencies are likewise under threat. Fortunately, such laws have so far largely been struck down, but attempts continue.

None of this takes into account the far greater work still done by pro-lifers outside of the pro-life label. Perhaps part of the reason pro-lifers are not perceived as addressing other issues is because they often compartmentalise their work on other issues. But we know, for example, almost the entire volunteer base for crisis pregnancy centres is religious, and almost entirely Christian specifically. And Christians (even the nasty evangelicals) do a huge amount of work looking after people after birth, even if in America they often have a scepticism of doing this through government. This is not just church work: even on secular metrics, Christians give more than non-religious people – in addition to what they give to their churches and faith-based organisations.

Christians – who compose the overwhelming majority of the pro-life movement in the US – give far more money even to secular causes and do far more volunteer work than non-Christians, and adopt at over twice the rate of the average citizen. In the US, 91% of religious conservatives give to charity, compared to 67% of others, and they volunteer at a rate 10 percentage points higher than the general population. Religious believers are far more likely to donate blood, to give food or money to homeless people, and so on. In Europe, Christians are 30 percentage points more likely than a non-religious person to volunteer, and 15 percentage points more likely to volunteer for non-religious charities. John Dickson’s excellent book Bullies and Saints, chronicling the good and bad of Christian history since the very first years, has a number of other cited examples.

Hence, it is clear that, in fact, under the pro-life label and aside from it, those involved in the pro-life movement – most often religious conservatives – are in fact quite a bit kinder than they are typically portrayed, when the empirical evidence is on the table. I say this not to blow the trumpet of Christians – but to show that certain allegations of hypocrisy do not always hit the mark, despite the Church’s many failings throughout history.

This is particularly clear when contrasted with the pregnancy support work offered by abortion providers themselves. Planned Parenthood’s own annual report, for example, cites over 350,000 abortions performed, but only 8,626 instances of ‘prenatal care’, an odd distribution of services for an organisation dedicated to women’s ‘choice’ (since the large majority of pregnancies are not aborted). This is despite receiving vastly more funding from the government – over $600 million in 2019-2020 even under a Republican government, for example. Evidence of pressure and coercion to abort is discussed under ‘How common is coercion?’

Unwanted children lead to educational and career problems

Of course, if the child is a person with equal rights, then educational and career reasons could never justify ending its life. While this seems like an easy and accurate response to the question, it’s not enough in itself – not because it’s true, but because given the ways women are often treated, especially the ways they are discriminated against for becoming pregnant, we all have a duty to think seriously and carefully about the educational and career challenges women face, and how best to resolve them. Hence, it is important to explore this question further.

There is no doubting that unwanted children can present challenges for the mother’s education and career. Wanted children do as well! But I do want to suggest that these issues have been overstated – and where they cause significant problems, there are solutions other than abortion. Hopefully this will be a helpful starting point for developing better policies and practices to protect women and girls in schools and workplaces who may face formidable challenges because of their situation.

As I say in many of these questions, an important factor to bear in mind is that abortion restriction does not necessarily lead to more unwanted children. If so, most of what I say here may well be irrelevant – when abortion is restricted, many women do not get pregnant in the first place, which is better for everyone. For more details, see ‘Does restricting abortion lead to more unwanted pregnancies?’.

Perhaps surprisingly, there is relatively little empirical evidence showing that childbirth hinders education, on average. We start with Upadhyay et al.’s 2015 paper from the Turnaway study, showing that women receiving abortions were more likely to achieve their one year aspirations than women giving birth. It will be helpful to consider this alongside McCarthy et al.’s 2020 paper from the same study looking at five year aspirations. In this study, the authors asked women one week after the abortion, “how do you think your life will be different a year/five years from now?” The researchers then coded these into positive, neutral, and negative expectations, and assessed their achievement insofar as they were able using data they collected separately (i.e. without asking the individuals whether they considered their expectation achieved). They coded positive expectations as ‘aspirational plans’.

The study in fact found that among women setting plans, there was no difference between the groups in achievement. But since women receiving abortions had more positive expectations, more of them overall were fulfilled. Further, there are a number of problems with the inference that women denied abortions are less able to achieve their aspirational plans:

1. The measurement of aspirational plans or hopes is extremely suspect. Participants were not asked for their hopes; they were simply asked what they thought would happen. Women giving birth probably felt less able to predict their lives, but were not asked what they hoped for from their lives. Life with a child is often less predictable; but this does not mean the parent has fewer hopes, ambitions, or sources of happiness.
2. Participants were not asked to appraise their expectations as positive; this was left to the researchers. But some of these decisions are extremely vulnerable to the researchers’ biases: for example, they coded the expectation: “my future is dedicated to my kids and their education” as a neutral expectation and “[the child] will probably be with me for the rest of my life” as a negative expectation, but it is perfectly possible that the participant thought of these in positive ways.
3. No attempt was made to weight expectations according to ambition/realism or importance. For example, “hopefully by then I’ll have a baby” and “hopefully I’ll be married by then” were effectively considered just as important as “I hope to get a dog”. This will bias the results towards favouring many more trivial positive expectations over fewer more profound positive expectations (such as having a baby).
4. The researchers included a bias towards positive changes by asking how the woman thought her life would be ‘different’ in a year or five years. But women who were already happy with elements of their lives had no way to answer this, and no way to show that their happy lives remained the same at follow up. Perhaps women giving birth were already somewhat happier with more elements of their lives, for example, feeling less need to begin a new relationship, perhaps already being in one, and so on (hence the rarer relationship expectations among women giving birth); indeed, perhaps these considerations are what caused them to give birth rather than seek an abortion at another facility. Importantly in connection with this is the fact that they found ‘stability’ was a common aspiration, and yet the precise question of the study selected against measuring any stability at all (moreover, there is some evidence that many women see having a child as a crucially important means of stability).
5. The setting of expectations is relatively unimportant; what is more relevant is actual attainment. The setting of expectations is likely to be significantly affected for women giving birth by the fact that Western society generally sends the message that having an unintended pregnancy is a very bad thing and will ruin one’s life; but as these studies and others have shown, what a woman expects during an unintended pregnancy, and especially one week after being denied a sought abortion, is not an accurate indicator of what women are actually able to achieve. Modern society also makes parenting needlessly labour-intensive, so the negative expectations of parenting need not be met.
6. Within one year, there was no difference in attainment of the plans actually set – the number of plans set may be irrelevant, for example, if women giving birth were already content with their lives.
7. The researchers didn’t assess women’s original goals prior to pregnancy, so were unable to say how denial of abortion affected prior plans.
8. There are other possible selection biases for which the researchers could not control; for example, it is widely thought that when women are deciding to continue an unplanned pregnancy, the opportunity cost is a salient factor. Perhaps the women who decided to keep the baby rather than seek an abortion elsewhere were less ambitious to begin with, and this is precisely why they decided to continue the pregnancy after being initially denied.
9. On the five year scale, while in multivariate analysis women giving birth had fewer aspirational plans, they were far more successful at achieving them, such that they actually had an overall higher probability of both setting and achieving an aspirational five year plan than women receiving abortions, though this difference was not statistically significant. This does presumably mean that women giving birth were less likely to suffer the disappointment of failed 5 year aspirations as well.
10. The study did not include positive outcomes the women did not expect but nevertheless achieved. These are particularly important for women giving birth, given a culture where women having unintended pregnancies are routinely told that their lives will be effectively over.
11. Finally, what is surely of importance is that life satisfaction overall was no worse long term for women giving birth (this point is also relevant for the other outcomes – income, education, mental health, and so on). While one week after the abortion, women giving birth had marginally lower life satisfaction, throughout the rest of the five years, they had higher life satisfaction than those receiving abortions. Likewise relevant to each of these outcomes is the fact that by 5 years, 96% of women giving birth were glad they were denied an abortion, and a further undocumented percentage were unsure.

A related Turnaway study paper by Ralph et al. in 2019 studied women’s educational attainment after having or being denied an abortion. They note that there is disagreement in the literature about whether women giving birth at young ages have lower education for pre-existing reasons or as a result of giving birth, and draw attention to some evidence showing that even the possible negative impact of childbearing on teen education does not extend to women in their 20s. They note too that much of the existing literature is from before 1990, when educational options for pregnant or parenting teens were virtually non-existent. They then find in their own study that being denied an abortion had no discernible impact whatsoever in the educational attainment of women seeking abortion, consistent with various other studies. They conclude that the Turnaway study suggests adverse educational outcomes are largely due to pre-existing factors.

Beyond this, there are a number of points to make very briefly:

1. A child can often be the stimulus for people to ‘get their life together’, particularly people in poorer socioeconomic positions. In their magisterial work on motherhood among less affluent women, Edin and Kefalas summarise: “Middle-class observers often believe that the lives of poor youth could be salvaged if not for the birth of a child—but this is seldom the case… The poor women we came to know often describe their lives prior to motherhood as spinning out of control. Over and over again, mothers tell us their children tamed or calmed their wild behavior, got them off of the street, and helped put their lives back together. Children can banish depression, calm a violent temper, or serve as do-it-yourself rehab from alcohol and drugs. Children—and the minute-by-minute demands they make on their mothers’ time, energy, and emotions—bring order out of chaos… there were startlingly few “if only” tales of how “coming up pregnant” wrecked dreams of education, career, marriage, or material success. Instead, mothers repeatedly offered refrains like these: “I’d be dead or in jail,” “I’d be in the streets,” “I wouldn’t care about anything,” “My child saved me,” and “It’s only because of my children that I’m where I am today.” For all but a few, becoming a mother was a profound turning point that “saved” or “rescued” them from a life either leading nowhere or going very wrong.”
2. Much of the ‘motherhood penalty’ comes not from motherhood itself, but from the rampant discrimination against mothers in workplaces – including, as mentioned elsewhere, at Planned Parenthood. This is a reason to fight that discrimination, not encourage women who would otherwise keep their child to abort because of it.
3. While it is uncontroversial that having small children usually involves a productivity decline, the evidence at later stages is far more equivocal, suggesting that the benefits of parenthood at later stages can often compensate.
4. Plausible mechanisms have been identified for this compensation in productivity: for example, Graves and Ruderman show how parenthood and work can facilitate each other, and family commitments strengthen leadership, other task skills and overall-wellbeing, as well as positively affecting mood and providing sources of support. Scientific American has a helpful summary.
5. Part of the reason for work and family conflict is because of modern gratuitously hyper-intensive parenting. Astonishingly, a working mother today spends as much time on childcare as stay-at-home mothers did in 1975. In light of this, it is no wonder balancing work and childcare are difficult.
6. Finally, recall the impact that family breakdown has had on families’ economic situation, particularly among the poor. The marriage bonuses to one’s career and one’s finances are well known, as are the economic difficulties of single parenting. These costs were particularly high for ethnic minority groups, lower socioeconomic classes and women. Hence the description of Akerlof et al. that abortion and contraception jointly, by dramatically changing family structures, had led to the ‘feminisation of poverty’.

There is a huge amount more that could be said – unfortunately I cannot do so yet as much of this work is part of a working paper. Please do let me know if more information is needed. I will try to make the paper available soon.

Unwanted children lead to poverty

Clearly, all of the last answer is relevant to this specific question: poverty depends in large part on education and career milestones. I recommend anyone interested in this question read that answer first, as the information there is key. There is often a tendency to project the preferences and expectations of affluent men and women onto less affluent men and women: as Edin and Kefalas, among others, show, the reality is quite different. In fact, polling in the UK shows that those in the lowest socioeconomic group were twice as likely to support a 12 week abortion limit (or less) than those in other socioeconomic groups. But what else can be said here?

There is another Turnaway study paper suggesting that women denied abortion were more likely to be in poverty, less likely to be employed, and more likely to receive public assistance, both 6 months and 4 years afterwards, than women who were permitted an abortion. Of course, this study suffers the same issues as the Turnaway study generally (described under ‘What about the Turnaway study?’). But there are other important limitations:

It is true that women who were denied abortions were more likely to be unemployed at 6 months and 4 years, but women denied abortions had far lower full time employment, and much higher unemployment, to begin with. Examination of the trends shows, in fact, that while both groups increased full time employment over time, women denied abortions who gave birth actually gained full-time employment at a faster rate – so much so that there was no significant difference between the groups by 4.5 years. Likewise, while it is true that women giving birth had higher unemployment rates at 6 months than women receiving abortions (as one might expect, not least because of the number of women choosing to look after their child full time at least for some months), they had far higher unemployment rates at baseline. Again, both groups decreased unemployment over time; but women giving birth’s unemployment decreased so much that by five years, they had marginally lower unemployment rates than women receiving abortions. If anything, the evidence suggests that being denied an abortion improves one’s chances of becoming employed over a few year period.

A second main outcome of the study showed that women giving birth had higher receipt of welfare. This is exactly as it should be and is no cause for concern; if anything, we should be concerned if the women, many of whom had a low income, did not have significant public assistance after having a child. The only measure of final outcome as opposed to benefits received in this category is having health insurance; in fact, women giving birth were more likely to have health insurance at 6 months than women receiving abortions, though this was no longer significant at 1 year.

Personal income was lower at 6 months for women giving birth. But again, this was true at baseline. And again, by 5 years, women giving birth had increased their personal income at a higher rate, so that the two groups had the same average personal income. Household income was the same in both groups throughout the study, but because of the changing household sizes, women giving birth were more likely to live below the federal poverty line. This was the only difference which was not already present at baseline. However, this gap narrowed over time so that the difference was non-significant by 5 years. Subjective poverty (reporting having enough money to meet basic living needs) decreased in both groups over time at roughly similar rates; there remained a difference at 4 years but primarily because there was a difference at baseline. So while there was some evidence that women giving birth were more likely to live below the federal poverty line, this does not appear to have caused a noticeable difference (given the differing baselines) in ability to meet basic needs.

So the Turnaway study’s results on employment and poverty are far more nuanced than has been publicised. If anything, women who gave birth appear to have gained employment at significantly higher rates.

Of course, all this neglects the many ways in which legalised abortion has made women and children worse off financially. This is perhaps best seen through the impact of abortion on family breakdown, which has led to the ‘feminisation of poverty’, disproportionately affecting women. To quote Akerlof’s conclusion again: “Just at the time, about 1970, that the permanent cure to poverty seemed to be on the horizon and just at the time that women had obtained the tools to control the number and the timing of their children, single motherhood and the feminization of poverty began their long and steady rise. As a result, United States poverty rates have been stubbornly constant for the last quarter century.” Again, family breakdown has been estimated to cost the US at least $112 billion each year.

Likewise, this neglects the other costs of abortion, individually or societally: increased costs from suicide, IVF, abortion and its complications, preterm births, STDs, mental health consequences (and effect on career). Those having an abortion may also miss out on the financial benefits of motherhood: motivation for one’s career, the ‘motherhood advantage’ (described in the previous question), increased efficiency, and increased emotional support available within the family. None of these are trivial, and many have considerable non-financial costs as well. For all these reasons, it is highly doubtful whether women are better off financially with legal abortion; in fact, there are many reasons (and empirical evidence) to think they are financially worse off.

In any case, the answer for women in poverty as a result of having a child is surely not to end the life of their child. The answer, as with women with born children, is surely to give them the financial and other support they need so that they are no longer in poverty.

Unwanted children and child abuse

A traditional argument for abortion is that it is compassionate for the children themselves: no child deserves to be unwanted. This is true – though we would never draw these implications for born children. We wouldn’t assume that because they were unwanted, they would be better off dead and therefore we should kill them. Rather, we should do as much as we can to find them a loving home where they are wanted, and to create a society where they are valued equally.

As I’ve remarked on a number of questions, the evidence that more unwanted children would be born is, in fact, very slim. If abortion legalisation increases risky sex (as it clearly does), and if it makes pregnancy/children less ‘acceptable’, then abortion legalisation could even increase the number of unwanted children (see ‘Does restricting abortion lead to more unwanted births?’).

In any case, this is an extremely unrealistic picture of the empirical evidence. In the overwhelming majority of cases, unwanted pregnancies result in wanted babies. Recall the words of Diana Greene Foster, lead author of the Turnaway study:

‘How do women feel about having been denied an abortion? Initially, bad. But over time, most of the women who ended up carrying the unwanted pregnancy to term reconciled themselves to their new reality, especially after their babies were born… Women don’t often say they want an abortion for fear of what an unwanted pregnancy would do to their mental health. And mental health rarely seems to suffer, even when abortion is denied… Most of the women turned away, over time, reported that they were happy they had the baby.’

Foster reports further that only 9% of women who were denied abortions had poor maternal bonding, and even then, the overwhelming majority of these were still happy they had the baby.

On the whole, children from unwanted pregnancies end up no worse off than the average child on a wide variety of outcomes, and marginally worse off on a few. Let’s look at the recent literature. Jessica Houston Su found that children from intended births scored an average of 4.04 on a depressive symptoms score, compared to 4.77 for children from unintended births. The worst possible score was 60, and best was 0. Given the range, this is a negligible difference – just 0.73. To give an indication of how much worse this would make someone’s life on average, 1 point could be ‘scored’ by feeling hopeful only 4 days in the last week rather than 5-7, or having one night’s restless sleep in the last night. The difference between children from intended and unintended births was even less than that. And the most important point? Even then, the author concluded that results from the more complex models showed that ‘there is little to no causal relationship’.

The Turnaway study also compared children born after being denied an abortion with children born to a mother who had previously obtained an abortion. They also found no significant difference at all in perinatal or child health outcomes. Children born from unintended births had marginally worse gross motor outcomes, and had a significantly higher likelihood of poor maternal bonding – but as mentioned, the rates were still very low (9%) and even most of these women were glad they had the baby by the child’s 5^th birthday. Hence this study offers no support for the idea that ‘unwanted children’ suffer miserable lives and are better off not living.

Now, recall that abortion was supposed to be a solution to the problems of child abuse, and out-of-wedlock births. Larry Lader, the founder of NARAL, the leading abortion lobbying group in the 1970s, promised in 1974 that “The impact of the abortion revolution may be too vast to assess immediately. It should usher in an era when every child will be wanted, loved, and properly cared for.” NARAL then went on to vow in 1978 that “A policy that makes contraception and abortion freely available will greatly reduce the number of unwanted children, and thereby curb the tragic rise of child abuse in our country.”

Then recall what I said about abortion decreasing the ‘acceptability’ of pregnancy. It is not unreasonable to think that abortion has contributed to the general coarsening of attitudes towards children over the last half-century. And it is uncontroversial that it has led to a huge increase in risky sex and decline in shotgun marriages, and hence a rise in unconventional family structures, which are associated with significantly higher rates of abuse (as a child of divorced parents, I make no judgments, and am well aware that most unconventional families do not involve abuse – nevertheless, the statistics clearly show higher rates). Likewise, abortion’s legalisation led to higher rates of male delinquency. All of these have multigenerational effects.

Abortion was never going to do much to solve child abuse, since the large majority of children subject to abuse originate in the context of a wanted pregnancy. Studies on the relationship between abortion and child abuse have shown mixed results – while some show that children born from unwanted pregnancies are more likely to be abused (though most are still not), others suggest an association in the other direction. Most studies on this topic are old, and many look only at child abuse likelihood within a given family – without looking at how abortion legalisation can affect child abuse on a societal level.

What we do know is that infant deaths from child abuse have steadily been rising since the early 1970s in the US, despite far greater efforts to prevent them. Finkelhor and Jones note that the data show big increases in reports of child physical and sexual abuse in the 1970s and 1980s in the US, and not all of these indicators can be explained by increased reporting: “trend data for child well-being indicators mostly show a deterioration in the 1970s and 1980s”.

Hence abortion has uncontroversially made the problem of out-of-wedlock births worse. The evidence about its impact on child abuse in individual families is mixed, but this generally ignores the long-term effects of abortion on family structure, male delinquency, and so on. There is some provisional evidence that abortion has made the problem of child abuse worse on a societal level.

Does abortion reduce crime rates?

A famous paper from 2001 argued that legalised abortion led to reduced crime rates. I hope to comment on this in more detail in time, but for now I highly recommend Michael New’s brief discussion of this paper, and for a far more detailed analysis of some of the relevant evidence, Jonathan Klick’s paper summarising the evidence on this topic. It is safe to say that the original paper has received a substantial amount of criticism from a wide variety of sources.

In fact, as New points out, some have argued that abortion has increased crime rates. Akerlof’s papers, which I discuss elsewhere, are highly relevant here. Abortion legalisation is known to have contributed substantially to family breakdown, a key determinant of criminal activity. It has likewise caused an ‘extended adolescence’ of men, leading them into higher delinquency rates for more of their adult lives than before. Hence there are good reasons to support that abortion legalisation has had the opposite effect, substantially increasing crime. Recall that Akerlof is a Nobel prize-winning economist, and his wife (who co-authored one of these papers), Janet Yellen, is President Biden’s Secretary of the Treasury – presumably no pro-life activist!

Is unsafe abortion economically burdensome?

“Abortion is cheaper for society than raising a child”

Is the world overpopulated?

What about the environment?

Is unsafe abortion economically burdensome?

Some abortion advocates claim that treating complications of unsafe abortion is very expensive, and hence argue that this is one reason to legalise abortion. There is something very sinister about very wealthy countries pressuring poor countries to make a decision of such profound importance on the basis of relatively minor economic considerations, but we will set that aside for now. The claim is that many women are treated in hospital from complications of unsafe abortion, costing the health system a lot of money. There are a huge number of problems with this claim:

1. Many of these complications – perhaps most – are, in fact, from miscarriage (see ‘How many abortions occur when abortion is illegal?’).
2. The argument assumes that illegal abortions stop when abortion is made legal. Not only do they not stop, in many cases they do not even decrease (and in some cases even increase) – see ‘Does legalising abortion prevent women dying from backstreet abortions?’
3. The argument assumes that legal abortions a) replace only illegal abortions, and do not increase independently; b) cost little in themselves and c) have few complications. But none of these are true. The total number of abortions dramatically increases (see ‘Do pro-life laws work?’); they cost a significant amount (abortion in the UK is estimated to spend £118 million a year on abortion alone, excluding complications); and a significant proportion of women require hospital care for complications (see my chapter on telemedicine).
4. There are many other economic costs of abortion. For example, increased preterm birth causes enormous hospital costs. Calhoun et al. estimated that the increase in preterm birth costs from abortion in the US came to over $1.2 billion a year in neonatal costs alone. Then there are ongoing costs from resulting disability such as cerebral palsy, a lifelong condition often requiring significant medical care.
5. Then there are the costs of depopulation: most Western countries, other than those with enormous immigration, have ageing populations which are causing huge financial problems for the health and social care system. Even in the UK where we have lots of immigration of working age people, we still have a deeply struggling healthcare system because we have too few workers to support the older population.
6. Abortion legalisation also causes a big increase in STD transmission; in the US this is estimated to cause $4 billion a year in healthcare costs. This will be higher in countries where HIV is more prevalent.
7. Abortion causes increases in suicide, alcohol and drug abuse, and family breakdown (see the questions on all of these), all of which have effects down multiple generations, and enormous healthcare, social and economic costs. Perhaps the most significant of these economically is family breakdown, which has been estimated to cost the US at least $112 billion each year through its impact on poverty, crime, education, and tax.
8. Abortion causes delayed childbearing and fertility gap (women having fewer children than they desire), leading to enormous increased (economic and physical) costs associated with IVF.

Again, a simplistic reading of the evidence suggests that laws protecting children and mothers cause some economic burdens. But these are far, far outstripped by the economic burdens of widespread legal abortion.

“Abortion is cheaper for society than raising a child”

A slightly different economic objection suggests that while abortion has costs, the costs for society of birthing and raising a child for 18 years are far greater. Where does this reasoning go wrong?

First, it goes wrong for the all the reasons described above. Second, it goes wrong because most women seeking abortion would never get pregnant in the first place, according to the empirical literature (see ‘Does restricting abortion lead to more unwanted births?’).

Third, it goes wrong because it is a bizarre way of counting the economic impact of an additional person. Why think that the economic impact of a child should be calculated by summing up all the costs of raising a child and then ignoring all the contributions that child will then make as an adult? That reasoning is utterly insane. Think about it this way. Which country would be more economically successful – a country with 5 people, or a country with 20 people? Obviously, the country with 20 people (other things being equal). People, on average, contribute more than they take, over the course of a lifetime. So although pregnancy and raising a child cost more than abortion in the short term (ignoring the huge economic impact on society as described above), they easily make up for that cost in terms of what the child produces when fully grown.

For all these reasons, the argument that abortion is cheaper than childbirth and childrearing fails.

Is the world overpopulated?

I will try to keep brief about this central question of demography, about which volumes and volumes have been written. Until the 1990s, population control was a huge component of abortion advocacy, mostly being pushed by extremely rich Western white men, and in large part wanting to preserve capitalism by a) keeping women in the workplace even if they wanted to be on maternity leave, and b) preventing large population increases in other parts of the world, which were seen as potential converts to communism and therefore needing to be limited. For much of the 20^th century, population control and abortion were also closely linked to eugenics, which was not held in as low esteem as it is today, being indeed very popular in ‘elite’ circles (naturally). For more on questions of overpopulation, I highly recommend leading environmentalist author Fred Pearce’s The Coming Population Crash, commended even by Paul Ehrlich, the forefather of modern overpopulation alarmism. Bricker and Ibbitson’s Empty Planet is also well worth consulting, and Angela Franks’ book on Margaret Sanger for a particularly in-depth look at the links between eugenics, population control and abortion.

The population control narrative was sidelined in the 1990s, with a ‘women’s rights’ centred approach taking over around the time of the 1994 International Conference on Population and Development. This is why many in my generation grew up hearing a great deal about overpopulation (in the late 1990s and early 2000s), but less so in recent times. As climate change gains renewed political salience, the topic of ‘voluntary’ childlessness is now coming up with greater frequency. This brings us to a first point: the threat of overpopulation is a problem not only for pro-lifers, but also for people who believe in a so-called ‘woman’s right to choose’. After all, what if women, on average, want more than 2.1 children (replacement rate fertility level), as they do across most of Africa? It is surely their choice – regardless of how it might impact the climate. So this is a potential problem for both pro-lifers and pro-choicers. This is perhaps why so many womens’ rights groups have been so hostile towards population control enthusiasts for most of the 20^th century (see, for example, the heinous forced sterilisation campaigns across India in the 1980s, and Chinese and North Korean forced abortion policies continuing until recent times), despite their working in concert at times. It is also why their alliance had to be based on reducing women’s desire for children. Although population control is not at the forefront of debates on abortion today, population control still rears its head in development policy across the world to this day.

Additionally, recall the point I repeatedly make on questions about the impact of ‘additional unwanted people’: namely, that limiting abortion has only a minimal effect on birth rates, since it causes people to be more careful about becoming pregnant in the first place (see ‘Does restricting abortion lead to more unwanted pregnancies?’).

Beyond this, let me make a number of brief points.

First, overpopulation predictions have been wildly wrong throughout most of history. There are perhaps 3 key figures in the history of this debate: Thomas Malthus, who published his concerns about overpopulation in 1798, William Vogt, who published his Road to Survival in 1948, and Paul Ehrlich, who published his The Population Bomb in 1968. All have been proven spectacularly wrong on a wide variety of predictions – for example, that in a short space of time, that hundreds of millions would die of starvation. Vogt, for example, also happened to precede notorious eugenicist Alan Guttmacher (of Guttmacher Institute fame) as National Director of Planned Parenthood. He warned in 1948 that ‘Britain now finds itself literally on the verge of starvation… Unless we [America] are willing to place fifty million British feet beneath our dining-room table we may well see famine once more stalking the streets of London.’

In fact, poverty and malnutrition have dramatically fallen globally over the last few decades, despite an increase in population from 3.5 billion in 1968 to around 8 billion today. Although world population has doubled, food production did so long before. Pearce notes that in the last half-century, the world has added only 10% farmland but has more than doubled food production. It is now widely agreed that there is enough food for everyone in the world and that hunger is mainly due to political factors rather than lack of production. Moreover, we have the technology to feed far more still, with far less land than currently used. It has been estimated that if the average farmer around the world reached the average yield of an average American corn grower, 10 billion people (which, according to current projections will never be reached) could be fed with just half of today’s farmland. Part of the key problem with Malthusian predictions is, therefore, that they have assumed technology will increase far slower than population. In fact, the opposite is the case. Despite exponential increases in population, we are increasingly able to tackle the problems faced by the world’s poorest.

This leads to my second point, which is that the risk of overpopulation has been greatly exaggerated, and it is now pretty much universally agreed that the world’s population will peak in the next century before declining again. The most recent estimate from The Lancet was that it will peak as early as 2064 at 9.7 billion, then decline to 8.8 billion by the end of the century. The technological innovations likely to be developed in that time mean that the largest ever world population will easily be able to be fed, and will of course have other needs met far more easily by that time as well (for the environmental impact, see below).

The total fertility rate in most countries has rapidly declined, even in places one might instinctively consider to have huge overpopulation problems. India, for example, while deliberating over whether to introduce policies limiting families to two children, already has a fertility rate below replacement level (around 2.1), and it is continuing to fall. Some countries, like South Korea, have a fertility rate around 1, meaning that their population will halve every generation. It is worth noting that population growth is deceptive, since the population will continue to grow even for some time after the fertility level drops below replacement (partly due to increase in life expectancy).

Third, the benefits of population growth are substantial – both in economic terms and providing ideas to solve the problems of ‘overpopulation’: recall, for example, that without people, we never would have managed to increase crop yield by such a radical extent in the last century. The economic benefits are likewise significant: countries have typically had huge economic booms from high population growth rates, particularly in Asian economics in the 20^th century. The economic benefits may be even larger in future: as the global population begins to plateau and shrink, countries will likely need to compete for immigrants as workers, and those immigrants can earn significant amounts to send home.

But the economic benefits can probably best be seen by looking at what happens when a country is underpopulated, as most of Eastern Asia and Europe (and increasingly many other regions) are. Latvia, for example, had a population of 1,880,000 in 2020. But by 2050, 30 years later, it is estimated to fall to 1,250,000 – losing around a third of their population. Japan currently sits at 126 million (2021), but will fall to just 88 million by 2065.

But loss of population is not the only difficulty. Consider these graphs of Japan. As can be seen, with a traditional population structure in 1950, the proportion of elderly people was very small. By 2055, the proportion of elderly people is absolutely enormous, with an ever-decreasing working age population able to support them (see this piece on how isolation, financial pressure, and lack of support from children are leading contributors to suicide in Japan, which has the highest suicide rate in the world). As another example, in the UK, 1 million people are likely to have dementia by 2025. But this will double to two million in just 25 years, by 2050. Yet the working-age population will stay largely the same during that time – but having to support double the number of people with dementia, which already creates an enormous economic burden – not to mention the many more elderly people needing healthcare and social support, who will also grow in proportion. The UK is already struggling to pay for health and social care, and this is likely to get far, far worse as time goes on. For one more example, consider this stunning fact: in 1940, the US had 10 workers for every retiree. By contrast, by 2030 Japan expects to have just two workers supporting every retiree. Underpopulation is a crisis.

It is for these sorts of reasons that countries with particularly low fertility rates and low levels of immigration see underpopulation as a central national priority and even as an existential thread in some cases. Singapore’s government-run dating service is not a joke; it is a very serious attempt to respond to the crippling crises the country faces as a result of depopulation. Virtually every country facing these concerns has serious national policies to increase their birth rate, because they realise how serious the problems of depopulation are (and those mentioned here are just a few). The UK and US have gotten off relatively lightly so far only because of immigration, and perhaps this is why concerns about underpopulation are not widely known to Anglo-American audiences – but given global fertility trends this will likewise decrease over time, and the effects on unsustainable elderly care are already being felt.

In short, overpopulation is no longer a serious threat in a simplistic sense, as even the Bill and Melinda Gates Foundation (traditionally strong supporters of population control) appear to agree.

Given the human rights abuses which have been perpetrated in the name of concerns about overpopulation – whether forced sterilisation in India, forced abortion in China, or affluent countries deliberately leaving others to starve – we should be very cautious about accepting these concerns uncritically. I mentioned William Vogt earlier, who preceded Alan Guttmacher at Planned Parenthood. What was his solution to his alarmism about population?

“The modern medical profession… continues to believe it has a duty to keep alive as many people as possible. Through medical care and improved sanitation, they are responsible for more millions living more years in increasing misery. They set the stage for disaster… The greatest tragedy China could suffer at the present time would be a reduction in her death rate.” Vogt complained that “The British must largely bear the responsibility… for the present situation of India. Before the imposition of the Pax Britannica, India had an estimated population of less than 100 million people. It was held in check by disease, famine, and fighting. Within a remarkably short period the British checked the fighting and contributed considerably to making famines ineffectual… While economic and sanitary conditions were being “improved,” the Indians went their accustomed war, breeding with the irresponsibility of codfish… Her people are steeped in superstition, ignorance, poverty, and disease. Mother India is the victim of her own awful fecundity. In all the world there is probably no region of greater misery, and almost certainly none with less hope.”

Of course, Vogt laced his endorsement of sterilisation cash incentives with a good dose of eugenics: “Since such a bonus would appeal primarily to the world’s shiftless, it would probably have a favorable selective influence.” Remember, these (and other) openly eugenic sentiments came in the immediate wake of the Holocaust, and just 3 years before Planned Parenthood considered him the perfect person to lead their organisation. This is perhaps unsurprising given the words of Margaret Sanger, who founded it:

“Those vast, complex, interrelated organizations aiming to control and to diminish the spread of misery and destitution and all the menacing evils that spring out of this sinisterly fertile soil, are the surest sign that our civilization has bred, is breeding and perpetuating constantly increasing numbers of defectives, delinquents and dependents. My criticism, therefore, is not directed at the “failure” of philanthropy, but rather at its success.”

I will talk more about the links between the abortion, eugenics, and population control movements under ‘Are abortion providers linked to eugenics?’. For now, it is worth recalling the damage done, especially to women, in the name of population control throughout the 20^th century, before overly confident (and usually empirically false) claims about overpopulation.

Again, I highly recommend Fred Pearce’s The Coming Population Crash in particular.

What about the environment?

Traditionally, overpopulation concerns have centred around food production. Classical population control fell into the (nevertheless very active) background in the 1990s, allowing abortion to become a ‘women’s issue’ rather than a demographic issue, partly in recognition of the atrocities perpetrated in the name of population control. But concerns about population have resurged in recent years in response to environmental concerns.

I hope my pro-life readers will forgive me for saying that I do not think pro-lifers have often given very substantive responses to these concerns. I think that climate change is real, and as far as I can tell (according to the subgroup of experts who I consider trustworthy and not politically motivated), significantly exacerbated by human consumption. This already causes a significant number of deaths globally, and will cause many more in future. Humans have a duty to steward the planet well, and especially insofar as the planet is important for nourishing humans and being inhabited by them, because humans are especially valuable.

Given this, how do we respond to the obvious suggestion that more people equals more carbon emissions, for example?

Well, some of the responses from the last question are again relevant: restrictions on abortion only lead to population increases if they are complete restrictions, and even then the effect size is small and temporary. And recall that these questions are equally challenging for those who think that having children is simply a matter of women’s choice: if women wanted large numbers of children, then they should presumably be allowed to have them regardless of the climate. So there are no easy answers here. Finally, recall everything said about the empirical population trends: that in fact, the world is quickly heading towards a population peak already.

There is more that could be said about the environmental concerns specifically, however. First, I can hardly improve upon this summary by leading climate ethicist (and advocate) Dominic Roser, where he offers a number of reasons (on which I elaborate slightly) why things are not so simple, including (but not limited to):

1. Emissions per capita are likely to drastically decline over the next few decades, making the impact of having children far smaller, a fortiori for more distant descendants. Since the impact of a child is often calculated in part on the basis of the emissions of one’s descendants, this becomes highly relevant.
2. There are, of course, enormous benefits to children, not merely costs. This is true both in general and with respect to the climate. Climate-conscious parents are more likely to have climate-conscious children. Climate-conscious children are likely to do net positive with respect to the environment.
3. Another benefit of children is that they come up with the solutions. The same booming population which caused concerns about overpopulation is the same large population which facilitated the green revolution, massively increasing food production in the 20^th century far beyond population increases. Children cause problems; but they often provide solutions at faster rates. Innovation comes from people. With fewer people, there will be less innovation. And innovation is desperately needed to solve (and ideally reverse) climate change. As Bryan Caplan puts it, population does not cause poverty, it causes prosperity. He notes that in the last 2 centuries, the population and quality of life both skyrocketed. This is because people = ideas: ‘The human imagination is the ultimate resource’. This is why despite finite resources, and huge increases in population, average commodity prices have steadily decreased for the last 150 years, adjusting for inflation. Air and water quality have likewise improved substantially in recent decades. The best solution to climate change is not gradually dying out with horrendous underpopulation problems. It is innovation. And innovation needs people.
4. Offsetting is possible: it has been estimated that you could offset the emissions from having a child with merely $160 a year, which is trivial in comparison to the other costs of raising a child – and this is based on US emissions, which are very high per capita in comparison to many other Western countries.
5. Crucially, the aim is to reach net-zero carbon emissions. If this is possible, then more people will not lead to more carbon emissions. 20 billion multiplied by zero is still zero. What is therefore necessary is to focus our attention on cleaner technology, which will have a far bigger impact than having fewer children. We may – and indeed hope to – arrive at a situation where each additional person makes no difference to carbon emissions. (You may worry that if we are carbon-neutral only by offsetting emissions, then more people equals more work required to offset emissions, and this may be unsustainable. But given that our global population is only expected to increase by another ~20% before falling, that the costs of offsetting are relatively small, and are likely to get far smaller with new technology, this does not seem like a huge challenge). Relatedly, even the researcher responsible for the most widely cited paper on avoiding children for climate reasons pointed out that the timeframe over which children make a difference is virtually irrelevant to the climate crisis.

Roser notes that there are also serious problems with overpopulation rhetoric and policy which need to be balanced: for example, the fact that it has frequently been used as a vehicle of racist population suppression. People in the West have consumption per capita far higher (by orders of magnitude) than those in many developing countries – and yet population suppression has been targeted very clearly towards people in developing countries. There are, of course, a variety of other concerns regarding women’s rights, coercion, and so on.

Obviously there are a variety of other environmental concerns which I cannot address in detail here (yet). But I hope that this general framework for carbon emissions (and the previous discussions about food production) shows that limiting population is not necessarily the solution to overconsumption – healthy and sustainable consumption is. Moreover, the world population is already set to peak, and abortion bans barely raise the population in any case. For all these reasons and others, it can be (and often is) widely agreed by environmentalists and sceptics alike that abortion access is not needed to solve environmental concerns, very serious though they are.

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.

“Abortion is 14 times safer than childbirth”: abortion and mortality risk

Do women die from not receiving abortions?: Savita and Izabela

Does legalising abortion prevent women dying from backstreet abortions?

“Abortion is 14 times safer than childbirth”: abortion and mortality risk

It is sometimes claimed that abortion is 14 times safer than childbirth – meaning that the mortality rate is just one fourteenth of the mortality rate from continuing a pregnancy. This is based on a 2012 study by Elizabeth Raymond, a doctor at Gynuity, an abortion advocacy research organisation.

When considering mortality rates after pregnancy and abortion, it is of central importance to discern exactly which deaths are being included and which are not. Deaths from suicide, for example, are often included under maternal deaths (relating to pregnancy), but not under abortion-related deaths. This is important since suicide is, in fact, the leading cause of maternal deaths in many developed countries. Likewise, ectopic pregnancies often count as maternal deaths, though they are clearly irrelevant to the relative safety of childbirth vs abortion, since an ectopic will generally have been discovered and treated by the time a woman has to decide whether or not to have an abortion. Indeed, deaths from abortion are often included as maternal deaths and are cited by abortion advocates as one of the leading causes of maternal mortality in developing countries. This is a strange categorisation if women having abortions are not already mothers, but we will set that concern aside for the moment.

The Raymond and Grimes study at least seems to avoid these typical errors, by specifically looking at deaths from live births, and therefore excluding deaths from ectopic pregnancies and abortions. Nevertheless, a variety of problems remain.

For example, Raymond and Grimes dismiss the long-term evidence on mental health by reference to a study by Charles et al. This review is now long-outdated, and was outdated even by the time of Raymond and Grimes’ paper (the Charlies review predated the APA report, NCCMH report, and Fergusson’s meta-analysis; for specifics on problems with the Charles review please email me); as I show in my section on mental health, the literature on abortion and mental health now clearly shows causal associations between abortion and mental health.

Another problem is that, of course, most women who find themselves pregnant want to continue their pregnancy. This statistic will not help them. What about those women who don’t want to be pregnant? Presumably the argument being made by abortion advocates here is that by limiting access to abortion, you will be subjecting such women to a higher risk of death. Some women will die as a result. One of the problems with this argument (and all arguments based on negative outcomes for women refused abortion) is that studies show that, generally, limiting abortion access has a very strong effect in preventing women from becoming pregnant in the first place: women who really do not want to be pregnant are typically much more careful not to become pregnant when there are limitations on abortion, just as one would expect. Hence, with moderate limitations on abortion, the abortion rate goes down, but the birth rate stays the same. With stronger restrictions on abortion (i.e. a complete ban), this can temporarily increase the birth rate, but often only temporarily and by a surprisingly small amount. So in fact, for most women who desperately do not want to be pregnant, limiting abortion access will not subject them to dangerous pregnancies, but rather will prevent them from the distress of an unwanted pregnancy in the first place. Hence it is questionable whether any extra women would die from pregnancy-related complications as a result of restricting abortion, even assuming pregnancy was risky and abortion was entirely risk-free (which, of course, is not true). For more on this, see ‘Does restricting abortion lead to more unwanted pregnancies?’

Another problem, which the authors concede themselves, is that maternal deaths are often unreported, and differentially by outcome, referencing a study finding that neither of the women dying from abortion in the sample were identified as having had an abortion from death records alone. In fact, this problem is far more widespread than even they imply, as noted by Reardon and Thorp in their systematic review on this topic. Among others, Calhoun and Reardon have detailed the problems with accurately identifying maternal deaths and abortion-related deaths. In fact, Finnish data have shown that pregnancy is far less likely to be mentioned in death records in the case of abortion than in the case of a live birth. This means that deaths from abortion are especially likely to be missed – by a large margin. The references given above contain more detail on this issue. This is not a problem limited to the US: see my chapter on telemedicine abortion for further examples of how abortion complications are massively underreported.

This is obviously a critical problem: if a large proportion of deaths from abortion go unreported – as seems to be widely agreed – there simply isn’t a basis for the abortion mortality rate offered by Raymond and Grimes. While their estimate of pregnancy-related deaths is probably fairly accurate – it is not far off the maternal mortality rate in other developed countries – their estimate of abortion mortality is wholly unreliable.

For another critical problem, consider the following quote:

‘Chronically high levels of stress can wreak havoc on bodily systems from the brain to the heart, and accelerate the pace of biological aging, according to experts. For people of color, race-based stressors can take a heavy toll on health for a life-time – and even across generations.’

So reported a news release from Harvard’s TH Chan School of Public Health, in the context of the impact of racism on the physical health of people of colour. I have no doubt that this is true. Medical sociology has known for a long time that psychosocial factors have an enormous effect on physical health – so much so that they simply cannot be excluded. The problem is that they are rarely reported as causing deaths. Cardiovascular disease certainly is – and is hugely affected by stress. But the psychosocial issues themselves are never mentioned.

Why is this important? It is important because there is inevitably a bias towards counting the riskiness of childbirth and abortion simply by their immediate obstetric complications. Although the data on these are unreliable in the case of abortion (and to some extent for live birth), it is possible that childbirth presents greater immediate obstetric risks than early abortions (for later abortions, things are less clear). But this entirely ignores the myriad ways in which pregnancy outcomes – and legislation relating to them – can affect one’s mental and physical health – indeed, across generations.

Another reason this is important is because most of the leading causes of death – if not all of them – among younger women are significantly affected by pregnancy outcomes. For example, the 5 leading causes of death of women aged 20-44 are unintentional injuries, cancer, heart disease, suicide, and homicide. All of these are strongly affected by pregnancy experiences, in ways which would very rarely show up on death certificates. It is known that women having an abortion are far more likely to die from unintentional injuries, suicide and homicide than women completing a pregnancy, other things being equal (see evidence below). A significant proportion of this disparity is thought to be causally related to the experiences of pregnancy, childbirth or the abortion. Having a completed pregnancy at a younger age is known to be protective against breast cancer, and most cervical cancer is caused by sexually transmitted disease, whose prevalence is known to increase in countries legalising abortion. Heart disease is hugely affected by psychosocial stressors (see the section on abortion and mental health), smoking and alcohol intake, which are all associated with abortion. As we will see below, death from heart disease is significantly associated with pregnancy outcomes. As I have suggested in ‘How abortion harms women’, there are myriad ways in which the legalisation of abortion contributes to poor psychosocial health through facilitating family breakdown, poverty, and so on. Some of these deaths can be quantified fairly easily; others are very difficult. They show how even women who do not have abortions can be adversely affected (in some cases dying) as a result of the societal and cultural changes resulting from the legalisation of abortion. Moreover, deaths where abortion is a contributing factor can occur many years later, and even across multiple generations (since e.g. poverty, family breakdown, and mental health difficulties and other conditions are often transmitted down multiple generations).

As I describe under ‘How abortion harms women’, the legalisation of abortion has been strongly linked with increased family breakdown and poverty, which both affect physical health in a wide variety of ways. It is also associated with preterm birth, the leading cause of death for under 5s worldwide, and increased sexually transmitted diseases, which can cause significant morbidity and even mortality in certain cases (e.g., HIV/AIDS). Of course, legalising abortion also increases the number of pregnancies dramatically, thus subjecting more women to the risks of both pregnancy and abortion.

This is only a brief summary, but it is clear that there a huge number of ways in which both abortion and its legalisation can significantly cause increased mortality, probably by a long way exceeding the very low number of women who would die from unwanted pregnancies if abortion were to be restricted. Most of these mechanisms will never show up in death records, of course.

It is therefore helpful to look briefly at the studies which look at overall mortality after abortion and pregnancy, which offer a more holistic picture (I address the question of maternal mortality rates and how they relate to legalisation under ‘Does legalising abortion prevent women dying from backstreet abortions?’). There are a number of record-linkage studies – where death records are matched to pregnancy outcomes throughout a country or state, giving a full dataset – in the US, Denmark and Finland. These show repeatedly that, for various reasons, the mortality rate after continued pregnancy is significantly lower than the mortality rate for both non-pregnant women and women having abortions, and this trend becomes stronger for women having multiple births or abortions. For example, in the most recent Finnish study of this kind,  the risk of death after abortion was triple the risk of death after giving birth, mainly because of a dramatic increase in the risk of accidents, suicide, and homicide. Even the risk of dying from medical conditions was marginally higher after an abortion than after giving birth, however – for reasons such as lower alcohol and drug abuse, increased health monitoring, and increased healthier behaviours more generally. The risk of a non-pregnant woman dying was double the risk of a woman giving birth.

These studies typically are not able to control for prior physical health, which is a major limiting factor (though many control for age, and some for prior psychiatric history). However, they are at the very least consistent with the idea that abortion causes a higher rate of deaths from suicide and accidents (often from drug use). Given that the studies claiming that birth is much more dangerous than abortion are so problematic in the ways described above, there is no convincing basis for making this sort of claim. At best, we do not know which is overall riskier. But in fact there is powerful evidence that abortion is riskier once indirect mechanisms are taken into account.

Reardon and Thorp have a helpful systematic review of the available record-linkage studies, and a fairly comprehensive overview of the ways in which abortion can increase the various causes of death. Calhoun has a good summary of some of the specific measurement problems with Raymond and Grimes’ initial study.

Do women die from not receiving abortions?: Savita and Izabela

In recent years, there have been major headlines – and protests, and even legislative changes – regarding the deaths of women who did not receive abortions despite their life begin at risk. In Ireland, Savita Halappanavar died of chorioamnionitis (effectively infection of the pregnancy itself – membranes and amniotic fluid; hence delivery of the baby is required to save the woman’s life) after not receiving an abortion/having the baby delivered. In Poland, more recently, a woman known only as Izabela died of septic shock, ostensibly after not receiving an abortion, though many of the details remain unclear. In Ireland, it is fair to say that this was one of the major, if not the major, event precipitating legalisation of abortion in the country. In Poland, there have been significant protests domestically and even internationally, since the media has tied this death to Poland’s tightening of its abortion law to remove disability-selective/eugenic abortion as a legal ground for abortion.

The deaths of both of these women are tragedies, and were likely preventable in both cases. Clearly something has gone wrong in both cases, that should be fixed. But what exactly was wrong?

In both cases, we should be clear that – as with virtually every other country in the world – abortion to save the life of the mother was legal. If there was a genuine threat to the mother’s life, as seems to be the case on both occasions, abortion/delivery was legal and should have been performed. There was no legal obstacle to doing so.

The very most that could be said, therefore, is that the law can sometimes be unclear exactly how much of a threat the pregnancy has to be to justify early delivery (leading to the baby’s death), and there may in theory be reasonable clinical disagreement about how urgent the situation is. If so, there seem to be multiple fairly obvious solutions: clear guidance on when delivery is indicated for the few conditions where these problems can arise (chorioamnionitis, pre-eclampsia, and so on) or even a centralised on-call emergency service which physicians could utilise to obtain authorisation for an abortion in cases of doubt. In practice, this is probably unnecessary, since it is generally so obvious that delivery is required in emergency situations that any competent clinician should not need to discuss it with such a service. But such a service – or clear set of guidance – would minimise the chances of these issues arising from incompetent clinicians or rare genuinely difficult clinical scenarios. Such suggestions do seem to have been made by Izabela’s lawyer.

In the case of Savita, the issues clearly identified by the investigation were incompetent clinical recognition of the condition and incompetent clinical decision-making, among other things. I hesitate to speculate on exactly what went wrong in the case of Izabela, since we know so few details – this is one part of why it is so grossly irresponsible for people to use her case in this way.

Let’s look at specifics in both cases.

In Savita’s case, as I mentioned, Irish law clearly allowed abortion in these cases – and this possibility was clearly exercised for many years. The investigation identified 3 ‘key causal factors’ leading to her death: 1) inadequate assessment and monitoring preventing the team from recognising her deterioration; 2) failure to offer all management options to the patient; and 3) non-adherence to clinical guidelines relating to the prompt and effective management of sepsis, severe sepsis and septic shock. While 2) relates to the failure to deliver the child – and delivery of the child might well have saved Savita, though not necessarily – this failure was not because the law prohibited it, but because the clinical team made major errors in recognising the severity of the situation. The report noted that ‘Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have lead to reconsideration of the need to expedite delivery’ – that is to say, if the clinical team had made a correct assessment of the clinical situation, they would likely have delivered the child in accordance with the law. This was fundamentally a clinical failure, not a failure of the law on abortion.

For a more comprehensive examination of Savita’s case, see my blog post on it here.

The circumstances leading to Izabela’s death are more complicated – or, rather, less certain. Very few facts are known at all, with only a few media reports of comments from the lawyer or family members. As I said, this is part of what makes the exploitation of her death for ideological purposes so grossly irresponsible. This is made worse by the fact that almost all the information we have is in Polish, making it easier for non-Polish media outlets to exaggerate, omit or fabricate various facts.

Again, Polish law allows – and always has allowed – abortion where the life of the mother is at risk. As Izabela’s lawyer pointed out, the threat does not even need to be direct or serious. This did not change with the recent tightening of the abortion law to prohibit disability-selective/eugenic abortion. The lawyer – our main source trying to connect the law with her death, even said: ‘I am far from saying that the death of this patient is a simple consequence of the judgment of the Constitutional Tribunal. The wording “consistency” means a cause-and-effect relationship, that is, if it were not for the sentence, the patient would not die. We cannot talk about such a relationship here’. The lawyer at the same time noted that an investigation was underway for ‘medical error’ – most likely the same sort of errors as in Savita’s case, at another point claiming that medical error was likely the main problem. The hospital in question had previously been criticised and fined for bad conditions in general. And the preliminary report suggests that the hospital had similar problems at the time of Izabela’s death, with clinical failings specifically responsible for Izabela’s death. In summary, all the evidence we have suggests that the case was very similar to that of Savita.

It might be thought that, since the baby had a disability which eventually led to the life-threatening situation, allowing abortion for disability would have prevented Izabela’s death by allowing her to abort long before her life was threatened. The problem with this claim is that according to both the lawyer and Izabela’s mother, Izabela wanted to keep the baby despite its disability. Izabela’s mother even claimed that the baby itself was healthy according to the autopsy. Although it remains unclear which condition the baby was thought to have had, a recent New York Times article pointed out that many (though not all) prenatal tests are usually wrong – not only sometimes – when they detect a disability.

Perhaps some of these claims are false. But even if so, that only strengthens my ultimate point, which is that we simply do not have anywhere near enough details about this case in the public domain to say what was the cause of her death, whether the baby was healthy, whether she would have been saved by a different law, and so on.

For this reason, it is wrong – in my view, appalling – to exploit Izabela’s tragic death in service of liberalised abortion laws in Poland or elsewhere. There is no evidence that she would have been saved by a different law, or that she wanted an abortion for disability. Even if there were, there are alternative remedies to prevent deaths attributable to poor clinical decision-making in these situations – clear guidance, or emergency on-call doctors/lawyers to advise in situations of doubt. I think it is fair to call for some of these measures. But to suppose that the law needs to allow for abortion in wider circumstances is completely erroneous and exploitative.

In summary, in neither case was the law responsible for the deaths of Savita or Izabela. In fact, in both cases, the law already clearly allowed for delivery of the child/abortion if the mother’s life was at risk, as it was in both cases. To the best of our knowledge, neither mother sought an abortion until that point, and at that point it was clearly legal. It is highly irresponsible, degrading to the victims, and – in the case of doctors – highly unprofessional to exploit these deaths for ideological purposes.

Does legalising abortion prevent women dying from backstreet abortions?

Perhaps the most common argument for legalising abortion throughout history is that women will get abortions either way; and if it is illegal they will be unsafe and women will die as a result. Hence, it is better to legalise abortion even if you oppose it. This argument is supposed to be powerful because it doesn’t rely on arguing a controversial moral position on abortion. It is a simple practical argument.

Since I’m writing a book on this topic I’ll try my best to keep this as a summary overview, but will write more in time. I’ll just survey the key points rather than giving a full answer. You’re welcome to contact me for more details.

The first thing to say is that one of the key premises is known to be false: abortion restrictions do, in fact, stop abortions. For more on this, see ‘Do pro-life laws work?’

Second, deaths from abortion are frequently fabricated, outdated or misrepresented. For a recent example of fabrication, see here. More commonly they are outdated – from the 1980s or (usually at best) 1990s, since when maternal mortality and abortion mortality have changed dramatically. And they are almost always misrepresented. Sometimes this is by taking the upper end of an estimate rather than the average, or most recent, or most robust. More commonly, almost every statistic refers to ‘abortion’: to most people, ‘abortion’ means ‘induced abortion’. But it also includes spontaneous abortion: that is, miscarriage. In some statistics it even includes ectopic pregnancy as well. So any woman who dies from a miscarriage (these can cause infection and bleeding) or ectopic pregnancy is included in deaths from ‘abortion’. These are then attributed to ‘unsafe abortion’, as if all these deaths were caused by backstreet abortions. Since there is significant evidence that most of these deaths are caused by ectopics and miscarriages, the number attributable to backstreet abortions is usually less than half this number/percentage.

Third, most abortion mortality can be eliminated with good post-abortion care. This is why abortion mortality was reduced to minimal levels in most Western countries before abortion was legalised.

Fourth, most abortion mortality has been eliminated by safer methods of illegal abortion. Of course, unsafe methods remain. But by and large, misoprostol is widely available in the developing world, or surgical abortions (as they were in the US prior to legalisation). And this is widely regarded as safe: so much so that the US Women’s March recently asked people not to use coathanger imagery because it would ‘reenforce right-wing talking points that self-managed abortions are dangerous, scary and harmful’. So what was once the foremost argument for abortion legalisation (and still is in most of the world) is now branded a ‘right-wing talking point’.

Fifth, legal abortion has moved in the opposite direction, moving towards self-managed abortion with misoprostol +/- mifepristone with no in-person contact with a healthcare professional (see ‘Is telemedicine abortion safe?’). Hence illegal and legal abortion are becoming increasingly similar in safety.

Sixth, legalising abortion does not necessarily prevent illegal abortions. In fact, in most countries with studies on legalisation, legalisation has not resulted in any decrease in illegal abortions. It has only resulted in an increase in legal abortions for people who otherwise would not have had one.

Seventh, legalising abortion increases the number of overall unwanted pregnancies, thereby exposing more women to the risks of either pregnancy or abortion.

For all these reasons, the empirical evidence shows a variety of trends:

1. Affluent countries with pro-life laws have very few deaths from abortion. Malta has had no maternal deaths from any cause in the last 10 years, and Poland has the lowest maternal mortality rate in the world. Likewise with Chile, South Korea, (pre-legalisation) Ireland, and many parts of the Middle East.
2. Less affluent countries with liberal abortion laws have many deaths from abortion – South Africa, Mozambique, Ethiopia, Ghana, India, and so on.
3. When abortion is legalised, the trend in maternal mortality and abortion mortality is almost always virtually unchanged. In a few cases, mortality and morbidity increase upon liberalisation, as in the Netherlands, Rwanda and Ethiopia.
4. Countries banning abortion continue to see a gradual decline in maternal mortality and abortion mortality.
5. Hence, the overall picture is that women dying from abortion is a function not of the legal status of abortion, but the quality of emergency obstetric care.

All the references for these claims can be found in my published paper on Malawi, summarised on the Journal of Medical Ethics blog.

In addition, of course, as I pointed out in ‘Abortion is 14 times safer than childbirth’, abortion and its legalisation cause increased mortality of women and children in a variety of other ways. This was particularly noticeable in South Africa, where legalisation was followed by an enormous increase in maternal deaths from HIV/AIDS. While there would have been an increase anyway, we know that abortion legalisation leads to a 60% increase in STD cases, so this probably caused many more deaths than otherwise would have occurred.

Finally, of course, even if legal abortion did reduce maternal mortality, and even if it made no difference to the number of abortions, it would still be unjust. It used to be argued by defenders of the slave trade that keeping the slave trade ‘safe and legal’ was better than unsafe and illegal. They even argued this was better for the slaves: by regulating the trade, you could ensure that ships had sufficient space so that the people kidnapped into slavery to move around, as compared with the horrific conditions in the illegal trade. Of course, this is ridiculous: the slave trade was an affront to the dignity of human beings taken into slavery, and the empirical claim (that laws do not suppress the trade) is implausible by a simple look at the evidence. Both are true in the case of abortion.

As I said, I am working on a book project on this topic, and I know there are many related empirical claims worth examining in more detail. I am happy to answer further questions if needed.

Is telemedicine abortion safe?

Does abortion pill reversal work?

Is telemedicine abortion safe?

During the COVID-19 pandemic, a small number of countries implemented full telemedicine abortion, whereby a woman could obtain abortion pills in the post to take at home without ever seeing a medical professional in person. It has been claimed that this is perfectly safe and effective – some even claim it is more safe and cost-effective because it leads to abortions at earlier gestations, therefore leading to fewer complications.

A number of concerns have been raised, including by some of the UK’s most senior medics, that such a system is unsafe, for various reasons:

1. Safeguarding: Coerced abortions are common, and the widely acknowledged best way to guard against these was for a woman to be seen in private in a clinic, without anyone else present. This is impossible through telemedicine. Moreover, abortion, especially repeat abortion (about 42% of abortions), is associated with domestic abuse, and women being seen in person can be a helpful way of screening such women for abuse.
2. Delayed gestation: Since there is no real determination of gestational age by examination or ultrasound (only by last menstrual period, which is not reliable), and since there can be a significant delay between receiving the pills and taking them, women can take (accidentally or deliberately) abortion pills long past the ‘safe’ limit (10 weeks), posing moral, legal and physical risks, including risk of Rhesus isoimmunisation. Abortions at home well beyond the limit of 10 weeks (and even beyond the general legal limit of 24 weeks) have occurred in significant numbers in the UK.
3. Ectopic pregnancy: Since there is no ultrasound or examination prior to the abortion, there is no opportunity to screen the woman properly for a possible ectopic pregnancy, which could rupture and cause fatal haemorrhage. Worse, since the symptoms of medical abortion and ectopic pregnancy are very similar, symptoms of a ruptured ectopic could be masked by the symptoms of medical abortion, which typically last 2 weeks and often more. Ruptured ectopics have been seen in the UK and elsewhere from abortion without ultrasound.
4. Interval between mifepristone and misoprostol: to be fully effective, the correct interval must be observed between the two drugs. Lack of proper interval can lead to various complications. If the administration of the drugs is not observed, the interval can be well outside the appropriate limits.
5. Limited sexually transmitted disease testing: Department of Health data from the UK show that 10-12% of women having abortions were not screened for chlamydia in the years leading up to telemedicine, while 20% were not screened in 2020. This lack of screening will probably lead to increased transmission of chlamydia in the population.
6. Limited contraceptive provision: Of the different contraceptive options, only LARCs (long acting reversible contraceptives) are reliable with typical use – other non-LARC options have 70-94% effectiveness, meaning they fail at a rate of 6-30% per year. Over several years of use, it is not at all unlikely that they will fail. Contraceptive injections have a typical use failure rate of 94%, meaning that over 10 years there is a 46% chance of becoming pregnant, for example. The chance of becoming pregnant using condoms alone over 10 years is more like 86%. Hence LARCs significantly affect the number of unwanted pregnancies. Prior to telemedicine, around one third of women received LARCs after abortion. During telemedicine, only 8.7% did.
7. Lack of examination for other findings: Examination (perhaps including blood tests) could pick up on a variety of other potential issues, such as anaemia, reproductive tract infection, or multiple pregnancy. Anaemia would put a woman at greater risk of severe problems from haemorrhage as a result of the abortion, and multiple pregnancy would likewise complicate the procedure (and perhaps affect her decision). Abortion can likewise be significantly complicated by pre-existing infection.

This is only a very short overview of the problems. For a full summary of these issues, with references, see my Routledge book chapter on the topic (available on request).

Does abortion pill reversal work?

I currently have a paper under review on this topic, which is available on request. The key points are:

1. People who support choice should support research towards, and the availability of, abortion pill reversal. It is odd that people who are pro-choice are so vehemently opposed to it.
2. There is some provisional evidence it works: the mechanism makes sense, it works in animal models, and there is a reasonably large case series with promising results (and a cancelled randomised trial, which is too small to say much from but which also looked promising). However, more work is needed. Still, as long as women are informed that the evidence is relatively limited (but still promising), it should be available to them.
3. The evidence of safety concerns is completely spurious, relying on a minuscule study finding that one woman in the treatment group went to hospital for haemorrhage (but needed no treatment at all). Two women in the control group had haemorrhages, but for a variety of reasons (including the fact that these women did not receive the treatment, by definition) this says nothing about the safety of abortion pill reversal.
4. Hence, as long as women are appropriately informed, abortion pill reversal should be available on a provisional basis. Further research should be conducted.

For more detail, see my paper.

Immediate complications of abortion

Does abortion cause breast cancer?

Does abortion cause preterm birth?

Does abortion cause infertility?

Does abortion cause sexually transmitted disease?

Immediate complications of abortion

Immediate complications of abortion happen are very common. Almost all complications are much more common at later gestations. Some are much more common in medical abortion (e.g. haemorrhage), while others are much more common in surgical abortion (e.g. uterine perforation).

More rarely, abortion can cause uterine rupture. This is more common with a history of caesarean section, after which the risk can be up to 0.4%. Uncommon, though not rare, in the case of surgical abortion are uterine perforation (generally around 0.1% in first trimester and much higher later) and cervical trauma (generally 0.05-0.1% in first trimester, just over 1% in second trimester): “Women must be informed that, should one of these complications occur, further treatment in the form of blood transfusion, laparoscopy or laparotomy may be required.”

Haemorrhage

Haemorrhage after abortion, especially medical abortion, is common or very common. Studies on haemorrhage vary widely, partly because of poor reporting and different definitions of haemorrhage. The RCOG claim that national data show <0.2% of abortions involve haemorrhage, but Department of Health data are known to massively underreport abortion complications, so these data are not only useless; they barely constitute data at all. Freedom of Information data from individual hospitals has shown a 2.3% rate for haemorrhage treated in hospital. Data from Finland, which has some of the most complete reporting and record-linkage systems in the world, found 2.1% haemorrhage rate for early surgical abortion and 15.6% for early medical abortion. 2%, for comparison, would mean around 4,000 women a year in the UK alone. A total complication rate was found of 5.6% for early surgical abortions, and 20% for early medical abortions, with 4% having multiple adverse events. There were 4 deaths in 20,000 surgical abortions and 2 deaths in 22,000 medical abortions. Bear in mind everything said in the question on mortality rates, and the fact that these abortions were all under 9 weeks – abortions beyond this point are significantly riskier.

It is clearly true that haemorrhage rates differ massively in the literature depending on gestation, reporting ability, and definition of haemorrhage. But the rates are still substantive in the first trimester and only get worse later, and underreporting will always mean that the true rates are higher than reported. High haemorrhage rates are often downplayed by selecting very stringent criteria (e.g. requiring transfusion). This appears to be selective, given that no such stringent criteria were used to cancel a study on abortion pill reversal and disparage abortion pill reversal as dangerous because of the ‘haemorrhage’ risk. This is despite the fact that only one patient needed a transfusion (as occasionally happens in abortion generally), and this was a patient in the control group – no one who had progesterone to attempt to reverse the abortion needed a transfusion. Still, it was said that there were too many haemorrhages and the issue could not be explored further – with abortion pill reversal subsequently being smeared as dangerous in the media (my view on abortion pill is cautiously positive: I think better data are needed, but there is certainly provisional evidence for it, and no convincing evidence against its safety – see ‘Does abortion pill reversal work?’).

The reality is that whether or not a haemorrhage exceeds 500ml or requires transfusion, it is an adverse event which can be distressing to women, require emergency transport and observation/treatment in hospital, and which can be dangerous with baseline anaemia. It cannot be dismissed – and it is common or very common. Severe haemorrhage requiring transfusion is less common, but we have minimal reliable data on this question, since complications are often underreported and haemorrhage is often not specified in detail. Still, it certainly happens with relative frequency. For example, RCOG cite a study showing that 0.7% of medical abortions from 13-21 weeks required transfusion.

Infection

As with haemorrhage, infection is often underreported and studies vary significantly in estimates. However, even the RCOG concedes rates may be as high as 10%, making infection a common complication of abortion. The comprehensive Finnish data suggest this is the same between medical and surgical abortion – 1.7% infection rates were found in that study. This would work out to around 4,000 women each year in the UK, or potentially higher if underreported and if the estimates closer to 10% are accurate.

Authorities like the RCOG typically claim that infertility is not a consequence of uncomplicated induced abortion. But that is of no use to the woman who have an abortion complicated by infection, for whom there is no dispute that they are at risk of pelvic inflammatory disease, infertility and ectopic pregnancy. Given that infection after abortion is common, this is a serious consideration.

Incomplete abortion and continuing pregnancy

Incomplete abortion is, perhaps apart from haemorrhage, the most common complication of abortion, to which continuing pregnancy (i.e., the baby is still alive) is obviously related. Incomplete abortion – where the baby dies but is not fully expelled – poses a risk of infection and bleeding and hence needs to be treated, usually by surgical evacuation.

The RCOG report continuing pregnancy rates of 0.9% for medical abortion and 0.5% for vacuum aspiration. Again, this dramatically increases as gestation increases. The RCOG refers to a variety of studies suggesting around 5-6% surgical intervention rate after medical abortion, which fits with the Finnish data, Marie Stopes Australia data and UK Freedom of Information data. This would work out to about 12,000 women needing surgical evacuation each year in the UK. The rates for surgical evacuation after surgical abortion are significantly low, but it is still common.

The main systematic review examining the safety of telemedicine abortion reports a wide range of estimates for incomplete abortion or continuing pregnancy, again likely due to underreporting. Several studies show surgical evacuation rates of 10-20% even at early gestations, making this very common.

Hence, immediate complications after abortion are common to very common.

Does abortion cause breast cancer?

I am not in a position to say. Before making claims of this significance, it is important to be very familiar with the data and confident that you can draw conclusions from it. Since I have not yet looked at this literature in great detail, I will make no claim about whether abortion causes breast cancer; I think this is the intellectually honest approach to take. Hence I will say very little on this question and include it only for completeness.

What does seem relatively uncontroversial is that earlier age at first full-term pregnancy is associated with a reduced risk of breast cancer, as does a higher number of births. The standard view seems to be that this is a causal link, not an artefact of some confounding factor. Hence, insofar as abortion prevents a birth, it would seem to increase one’s risk of breast cancer relative to giving birth, even if not relative to someone who has not become pregnant. So far, I have not come across anyone disputing this specific claim – but I would be grateful if someone could show me otherwise. When authorities claim that abortion does not cause breast cancer, they seem (in every case I have found, but again I am open to correction) to be saying that it does not cause breast cancer relative to non-pregnant women. That says nothing about whether it removes the protective effect of giving birth, which appears to be relatively uncontroversial. So specification of the comparison class seems crucially important on this question.

Does abortion cause preterm birth?

Abortion is uncontroversially associated with preterm birth and low birth weight in future pregnancies. The main systematic review on the topic found an association with a dose-dependent effect – the more abortions, the higher the increased risk, from 36% from one abortion, to 93% for more than one abortion. Although the RCOG claim that there is insufficient evidence implying causality, the leading theories (e.g., instrumentation of the cervix and uterus, as suggested by RCOG) involve a causal relationship. Of course, this should be researched further.

The increased risk of very early preterm births is even higher. It has been estimated that abortion is responsible for around 23,000 very early preterm births each year in the US, around 1,000 extra cases of cerebral palsy each year as a result, and costs of $1.2 billion in neonatal costs alone (not including later costs of long-term disability). For context, preterm birth is the leading cause of death for children under 5 globally.

Does abortion cause infertility?

There is no dispute that abortion can cause infertility, despite some sources denying this. Abortion can cause pelvic inflammatory disease if complicated by an infection, and PID in turn can cause infertility. Whether abortion causes infertility at a higher rate than pregnancy does is more controversial.

Does abortion cause sexually transmitted diseases?

Not directly, as far as anyone knows. But the legalisation of abortion certainly increases their overall transmission. The reason is that abortion acts as insurance option against pregnancy, meaning that the overall expected cost of having sex is significantly reduced – abortion is always there if contraception fails, so people are more willing to have sex with people, and more willing to have multiple sexual partners. They are also less likely to use barrier contraception. As a result, the legalisation of abortion in a wide variety of countries has been shown in multiple studies to lead to a significant increase in sexually transmitted diseases – Klick and Stratmann estimate a 60% increase in gonorrhoea transmission as a result, for example, complications of which include pelvic inflammatory disease, infertility, miscarriage, and premature labour. They estimated that the additional costs of treating STDs from abortion’s legalisation could cost around £4 billion each year in the US alone. These costs are presumably significantly higher in areas with higher HIV prevalence, including, of course, the costs of death from AIDS. This is part of the explanation for South Africa’s massive increase in maternal deaths from HIV/AIDS following the legalisation of abortion in the mid-1990s.

What are the major studies?

Does abortion improve mental health?

Does abortion harm mental health?

Is it because of the stigma?

“Women having abortions have worse mental health to begin with”

Is the link causal?

“95% of women having abortions feel they made the right decision”

“Women suffer emotionally if they don’t get abortions”

What about the APA review?

What about the NCCMH review?

What about Gilchrist’s study?

What did Fergusson’s meta-analysis show?

What about the Turnaway study?

What about Steinberg’s Lancet study on suicide?

How common is ambivalence before an abortion?

Summary of abortion and mental health

What are the policy implications?

What are the major studies?

On my academic papers page, you can read my book chapter on ‘The mental health complications of abortion’. This covers the questions I address in this section in greater detail. I also have another forthcoming book chapter entitled ‘Abortion’s causal role in trauma and suicide’, available on request, covering similar material in a bit more depth.

This section will include discussion of a variety of key papers and reviews:

1. The Turnaway study is a study conducted by pro-choice researchers allegedly demonstrating many negative effects of denying women access to abortion. It compares the outcomes of women who had first-trimester abortions, women who had later abortions just under the clinic’s gestation limit, and women who were denied later abortions just over the clinic’s gestation limit, splitting the latter group into women who went to have an abortion elsewhere (or miscarried) and women who gave birth. It is spread across a wide variety of papers and claims that denying women abortion is associated with a wide range of negative outcomes for that women and her other children.
2. The APA review (2008) was a review of abortion and mental health by the American Psychological Association, another group openly committed politically to abortion rights. It concluded that ‘among adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater than if they have a single first-trimester abortion than if they deliver that pregnancy’. It thus limited its conclusions significantly, and even conceded that the evidence was more suggestive in the case of multiple abortions (bearing in mind most abortions are one of multiple). It ultimately based its conclusions on a single paper, Gilchrist (1995), noting that Fergusson (2006) and Gilchrist (1995) were the two best studies, but claiming that Gilchrist (1995) was slightly better. Fergusson (2008) was not published at the time.
3. The NCCMH review (2011) was a more comprehensive review conducted by the National Collaborating Centre for Mental Health. By contrast, it performed meta-analyses using the best studies available for a range of psychiatric outcomes. It claimed that Fergusson (2008) was the single best paper available on the topic – a study which concluded that there were indeed links between abortion and a variety of mental health disorders. It also agreed that women with an unplanned pregnancy were more likely to be suicidal if they had an abortion than if they continued the pregnancy, but said that when women explicitly with unwanted pregnancies were investigated, there was no significant difference either way. It said that there was insufficient evidence of an increased risk of other conditions. They said that women having abortions had a lower risk of psychosis than women continuing an unplanned pregnancy, seemingly arguing that this cancelled out the increased risk of suicide so that the overall risk of mental disorders was about the same either way. It appears to concede that multiple abortions are associated with an increased risk of anxiety.
4. David Fergusson has a body of work, having published a major study on abortion and mental health in 2006, which was considered one of the two best studies at the time. This was improved in his 2008 study, which was (and still is) considered as the best study on the topic. In 2009 he published a paper on a slightly different theme, more focussed on the prevalence of specific negative emotions after abortion and subsequent psychiatric outcomes. In 2013, he published a meta-analysis, improving upon the NCCMH review. This remains the most recent major review of the evidence. Fergusson’s primary studies and meta-analysis find that abortion is causally associated with a wide variety of psychiatric disorders including anxiety, suicidality, alcohol misuse and drug misuse.

Most contemporary guidance on this topic cites the conclusions of the NCCMH review, and sometimes the APA review as well. No further reason is typically given for omitting Fergusson’s analysis, or addressing the problems with the APA and NCCMH reviews. In the following questions, I will comment more on each of these studies and reviews.

Does abortion improve mental health?

Abortion is frequently justified on mental health grounds – indeed, 98% of abortions are officially justified under this reason in the UK, where ‘abortion for mental health’ functions as abortion on demand.

In fact, it is fairly widely agreed that there is no evidence that abortion improves the mental health of a woman experiencing an unwanted pregnancy. The leading researcher on abortion and mental health in the world – himself pro-choice – concluded in the latest major review on this topic: ‘at the pre­sent time there is no credible scientific evidence demon­strating that abortion has mental health benefits.’ The Royal College of Obstetricians and Gynaecologists – a professional body vehemently in favour of abortion access – says that ‘Women with an unintended pregnancy should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy’. The most high-profile study on abortion and mental health in recent years, led by leading pro-choice advocates, and which generally claims that denial of abortion is harmful for women, nevertheless concludes that ‘carrying an unwanted pregnancy to term was not associated with mental health harm.’ The primary researcher behind the study concluded: ‘I expected that raising a child one wasn’t planning to have might be associated with depression or anxiety. But this is not what we found over the long run… Women are resilient to the experience… at least in terms of their mental health… women’s symptoms of depression and anxiety are slowly relieved following an unwanted pregnancy, regardless of how that pregnancy ends.’

Does abortion harm mental health?

Because there is such a broad consensus that abortion does not improve mental health (relative to continuing an unwanted pregnancy), most of the research has focussed on whether abortion harms a woman’s mental health, once she has an unwanted pregnancy. In 2008, this was judged by the editor of the world-leading British Journal of Psychiatry to be on its way to becoming an ‘established fact’. The suggestion is now dismissed by some as being close to pseudoscience. So what is the truth?

The editor of the BJPsych said this in response to a study by pro-choice Professor of Psychology David Fergusson. This study found that abortion was associated with a 30% increase in the rate of mental disorder, and that 1.5-5.5% of all mental disorders may be attributable to abortion. Fergusson and his colleagues gave six further arguments that the link was causal. Their work is widely agreed to be top quality, even by the two major reviews some people use to deny the link between abortion and mental health problems (the APA review and the NCCMH review – see below). The NCCMH review explicitly said that Fergusson’s 2008 study was the single best quality study on the topic. Yet Fergusson was asked by the New Zealand government not to publish his results because of the potential political implications. This goes a long way towards explaining why so many continue to deny an association.

We will start with what the latest good quality evidence shows. In 2013, Fergusson himself undertook a meta-analysis of the best quality studies on abortion and mental health, and found a clear trend. Abortion was associated with increases of 28% for anxiety, 13% for depression, 69% for suicidal behaviour, 134% for alcohol misuse and 291% for drug misuse. The results generally persisted even when only the widely agreed best studies were used. Notably, the Turnaway study also found that alcohol misuse was massively reduced as soon as women were denied an abortion.

The link between abortion and suicidal behaviour is particularly important, not just because of the severity of another tragic loss of life, but because suicide has for a long time been the leading cause of maternal deaths in many developed countries, such as the UK. Pregnancy and childbearing are known to be major protective factors against suicide, so the causal explanation is perfectly plausible.

This increased risk of suicide is partly responsible for the fact that the mortality rate a year after abortion is triple the mortality rate a year after continuing a pregnancy (see ‘Abortion is 14 times safer than childbirth’).

The evidence is also uncontroversial that some women suffer post-traumatic stress disorder symptoms after abortion, with abortion-specific symptoms. Studies differ widely on the frequency of this (between 1.4% and 14.3%) and on whether the rates after abortion are higher than after pregnancy, but it is uncontroversial that abortion-specific post-traumatic stress disorder is a real phenomenon occurring commonly or very commonly (according to the standard definitions – page 38 – of ‘common’ and ‘very common’ used for intervention side effects). Even the minimum estimate of 1.4% would mean well over 10,000 women a year in the US each year getting PTSD as a result of the abortion.

Likewise, studies show that most women feel a range of negative emotions following abortion. Fergusson’s work in New Zealand – where abortion stigma is minimal – found that 71.1% of women felt sadness, 34.6% very much so. 63.5% felt guilt, 33.7% very much so. 60.6% felt no satisfaction at all. All of these would easily count – by a long way – as ‘very common’ according to the standard definition used for intervention side effects. Even in the Turnaway study, whose low participation rate and high attrition rate almost certainly selected out those who responded worst to the abortion, found that 17% still felt significant guilt five years later.

There is also evidence showing that women feel worse about their abortions as time goes on – so some studies may not capture the full psychiatric consequences of abortion if they have only a short follow-up period. APA review author Brenda Major found that as time went on, negative emotions about the abortion increased, while positive emotions and decision satisfaction decreased.

Is it because of the stigma?

It might be argued that the poorer mental health outcomes from abortion are primarily a result of the stigma attached to abortion rather than the abortion itself. It is not clear what the conclusion is supposed to be: even if this is so, for example, women should be warned of the poorer mental health consequences regardless of the exact mechanism. Arguably this is not an objection at all: negative attitudes towards abortion are the primary proposed intermediary mechanism for negative mental health outcomes. Though some have suggested that a sudden interruption of the hormonal changes in pregnancy may contribute, the primary supposed mechanism is from women recognising something troubling about the abortion itself. So perhaps the objection is supposed to be that external stigma from other sources is the cause.

It is, of course, likely that external stigma contributes to the negative psychological consequences of abortion. But there are reasons to think that this an incomplete explanation – and that even if it were a complete explanation, this would not necessarily be relevant to policy.

The first reason is that many of the studies showing poorer mental health after abortion are from countries with minimal abortion stigma; the most careful work from Fergusson comes from New Zealand, a strongly pro-choice country which recently managed to legalise abortion up until birth with minimal restrictions. This work shows not only that abortion is associated with poorer outcomes, but specifically that the large majority of women obtaining abortions feel guilt and other negative feelings about their abortion (see above). Some of the work linking abortion and suicide comes from Finland, which legalised abortion on mental health grounds in 1950 and more explicitly on socioeconomic grounds in 1970, and which has seen no significant attempt to restrict the law since.

Second, some stigmatising activity which has long been claimed to cause intense mental harm and trauma to women obtaining abortions has been found to have no significant impact on women’s feelings about their abortion. For example, the only studies examining women’s mental health in response to anti-abortion protestors outside clinics found that these protests made no substantive long-term difference at all—in the most recent study, by just a week after the abortion, no psychological impact from protestors was discernible.

Third, in the Turnaway study, 33 women (4.7%) with post-traumatic stress symptoms cited ‘the abortion experience or decision’ as the reason for their post-traumatic stress symptoms, with a further 3 citing ‘being reminded of abortion’ – for example, seeing small children. By contrast, only 4 said that ‘others’ reaction to abortion’ was the cause. The overwhelming majority of cases therefore were attributable to the abortion decision or experience, rather than the reactions of others.

Fourth, external stigma is likely never to be eliminated. Many people will always oppose abortion and will be vocal about it. Fifty years after Roe v Wade, opinion polling in the US has held steady, and enormous political advances have been made – Roe v Wade now looks closer than ever to being overturned with many states lined up to criminalise, or mostly criminalise, abortion as soon as the Supreme Court permits them. Even if stigma were the sole explanation for poor mental health outcomes, it is highly doubtful whether it is preventable – if not, then stigma is a given which must be factored into informed consent and other policy-making.

Finally, internal stigma is likewise ineliminable because of the reality of abortion. The testimony of women undergoing medical abortions demonstrates that women who did not at all expect to deliver anything resembling a human (and for whom internal stigma was likely low) nevertheless are not uncommonly alarmed by the sight of the embryo even at an early stage in pregnancy. An evidence review from the National Institute for Health and Care Excellence addressing informational needs for women undergoing abortion found that women were unprepared for viewing the baby even under 9 weeks:

‘was totally unprepared for seeing the embryo… became very sad… I could clearly see that it would be a human being.’

‘[I] just felt compelled, that I had to look… In hindsight I wish I hadn’t looked but I did, and that was probably the most traumatic thing I’ve ever seen or done. I thought ‘what on earth…?’

Later abortions, with a more recognisable baby, though less common, are still common—in England and Wales alone, there are around 40,000 abortions after 9 weeks, and around 13,000 abortions after 13 weeks. NICE highlighted evidence on second trimester abortion from Sweden, one of the most pro-choice countries in the world:

‘The women’s stories revealed how ignorant they were about the abortion procedure… The actual abortion of the fetus was an emotional experience, which they were not prepared for…some of them had decided in advance not to see but saw it anyway. One woman described that something hung in a string between her legs and realized after a while what had happened. The abortion of the fetus was not a pleasant sight and some described how they ‘broke down.’ The picture of the fetus was something they would never forget.

‘You could see the fetus, where the ears were, the arms, I was really frightened’…

Some of the women thought that they had killed a life and could never forget the pregnancy that was ended. They found it unnatural to have an abortion and experienced feelings of guilt and shame. One woman, although being certain of the decision, experienced serious regrets afterwards.

‘I have killed a life, a person that cannot live because of my decision and I will never ever forget’…

Furthermore, women also experienced a psychological pain, as anxiety, depression, and worry, which remained after the abortion and was described as varying from emotional disorder and reaction to emotional trauma…

‘the pain dissipated the thoughts a little, the bad pain pushed the other bad pain away and the other is more of a psychological pain’…

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

            ‘I will never forget the actual aborting… it was… it came like a shock to me’…

The women thought that it was difficult to foresee the grief before being in the actual situation. They expressed that the time period after the abortion was hard even if the decision to have an abortion had been their own. Some women still struggled with thoughts of whether they had made the right decision and talked about an understanding towards other women in the same situation. The women struggled also with the memory/picture of the fetus. They were astonished that some women could expose themselves to several abortions. The women’s emotionally difficult experience was brought up when they came home and some time afterwards. They experienced that the body recovered faster than their mind.

            ‘You can never forget this… I just want to wipe it out from my life’…

The women experienced strong negative feelings after the abortion, which were permanent, and the look of the fetus was disturbing.’

It is for this reason that abortion providers typically specifically advise women to look away and clinicians to keep the fetus out of the woman’s sight.

A significant proportion of women undergoing abortions likewise are morally opposed to abortion themselves. Studies from Sweden and Norway found that significant proportions of women had negative ethical attitudes towards abortion, while a study in Russia and the US found half of all women undergoing abortion thought abortion was morally wrong, with a further percentage unsure – in Russia’s case, after a century of legal abortion and one of the highest abortion rates in the world for the entire period. Though dated, an LA Times poll from 1989 – when pro-abortion sentiment was somewhat higher – found that 37% of those who had had an abortion said abortion was morally wrong, and only 39% felt it was morally right. One third of those who had had an abortion considered it murder. A 1996 University of Virginia poll found that 74% of all respondents considered abortion to be either murder or the taking of human life; if one third of all women obtain at least one abortion in their lifetime in the US, a significant proportion will fall into this category.

More recently, a study of 5,000 women obtaining abortions found that 17.5% felt abortion was the same, or “kind of” the same as killing a baby that is already born. Presumably a further – perhaps large – percentage feel that abortion is morally problematic even if not akin to infanticide: the same study found that 45% had spiritual concerns about their abortion. Again, presumably there are more who would have moral concerns about abortion without spiritual terminology. In the Turnaway study, 20% felt that abortion was morally wrong, with a further 15% thinking it depended on the circumstances. This is very likely an underestimate given the low participation rate and high attrition rate, both of which would select out those worst affected by abortion.

Abortion providers – perhaps those least likely to stigmatise abortion – are likewise confronted with considerable distress at the basic reality of abortion, at least at later stages. A study of Japanese nurses found that abortion after six months was the single most traumatic event nurses experienced, with every nurse experiencing it rating the trauma of it as 10/10. Feticide – an injection to end the baby’s life before inducing an abortion in order to prevent it being born alive – is widely described in dramatic terms: ‘Over half of the [fetal medicine specialists performing feticide] expressed internal conflict about the provision of feticide and the need to ‘separate yourself from it completely’. They described it as ‘brutal’, ‘awful’, and ‘emotionally difficult’, referring to it as ‘stabbing the baby in the heart’.’. Almost all fetal medicine specialists, the study found, have a line they do not cross – abortion on demand at any point in pregnancy is emotionally and ethically anathema even to most abortion providers.

Earlier in pregnancy, there is widespread unease among abortion providers even for second trimester abortions. This was described by abortion doctor Lisa Harris in a leading journal in favour of abortion access:

‘Kaltreider et al found that some doctors who provided D&E had “disquieting” dreams and strong emotional reactions. Hern found that D&E was “qualitatively a different procedure – both medically and emotionally – than early abortion”. Many of his staff members reported:

“…serious emotional reactions that produced physiological symptoms, sleep disturbances (including disturbing dreams), effects on interpersonal relationships and moral anguish.”’

Harris goes on to describe another abortion doctor who vowed to stick to 14 weeks as a limit, after seeing an arm pulled through the vaginal canal; ‘the reality is, this cannot be called ‘tissue’. It was not something I could be comfortable with.’ Harris then relays her own experiences as someone who still supports second trimester abortion access, and presumably still performs them: how, while performing a second trimester abortion, she had an uncontrollable visceral reaction which travelled ‘from my hand and my uterus to my tear ducts’ – since at the exact same time as she ‘separated the leg’ with a ‘quick tug’ and held the leg and foot in her forceps, she felt her baby of the same gestation kicking in her abdomen. She described another episode where she performed a 23 week surgical abortion (dilation and evacuation, or dismemberment abortion) and shortly afterwards visited a 23-24 week premature delivery, the baby ending up in neonatal ICU: ‘I thought to myself how bizarre it was that I could have legally dismembered this fetus-now-newborn if it were inside its mother’s uterus – but that the same kind of violence against it now would be illegal, and unspeakable.’

The literature on abortion providers’ attitude to surgical abortion is replete with similar sentiments. It frequently draws attention to the ‘coping strategies’ needed by nurses to ‘conceal emotions’, and the need for official psychological and emotional support programmes for people providing abortions. One study in the NICE evidence review reported a woman and medical trainee so shocked at the ‘little human being’ delivered that the woman’s partner had to calm down the ‘abandoned’ trainee.

For all these reasons, the objection that negative psychological outcomes from abortion are only the result of external stigma are unpersuasive. There will always be a level of ineliminable stigma attached to abortion as a result of its basic reality as killing human life; if not for very early abortion, at least for later abortion – and these are unlikely to become separated in the public mind for the foreseeable future.

“Women having abortions have worse mental health to begin with”

This is true, but it does not explain the evidence. The reason is that the best studies – cited above – control for confounding factors such as prior mental health. They found that even after comprehensive confounder control, having an abortion was still associated with poorer mental health than continuing an unwanted pregnancy.

Is the link causal?

Clearly, there is unassailable evidence of a causal link in some cases (e.g. in abortion-specific PTSD). There is also very strong evidence of a causal link in general: the explicit indexing of mental health problems to the abortion among many women, the obvious causal mechanisms (the frequency of women feeling morally or spiritually uneasy about abortion, the frequency of guilt, the protective effects of pregnancy and childrearing against suicide and alcohol/substance misuse), the persistence of association after thorough confounder adjustment, the dose-dependency, and so on. Fergusson offers a more complete discussion.

“95% of women having abortions feel they made the right decision”

This statistic comes from the Turnaway study, which I discuss under ‘What about the Turnaway study?’ In summary, there are a huge number of problems with the Turnaway study which make this an unreliable conclusion: in particular, the enormous attrition rate, meaning that a huge number of those invited to the study either declined or later dropped out of the study. Since women who found the abortion a more traumatic experience are more likely to drop out (see ‘What about the Turnaway study?’), 95% is probably a significant overestimate. This is confirmed by the fact that other studies of much higher quality have found that most women feel they made the right decision, though with significant levels of doubt. APA review author Brenda Major found that just 2 years later, only 72% of women were satisfied with their decision, and this decreased over time (and only 69% would make the same decision again). Fergusson found at age 30, 89% of women felt they made the right decision.

There is an often overlooked fact from the Turnaway, however, which mirrors (and even outweighs) the 95% statistic. This is that 98% of women refused abortions who kept the baby and raised it were glad they were refused an abortion by the child’s 5^th birthday (and the 2% included ‘unsure’). 85% of those who kept the baby and placed the child for adoption were glad by the child’s 5^th birthday – lower, but still high. On average, 96% of women who kept the baby until birth were glad they did so (or, one might say, were forced to do so). The remaining 4% (or 2% for women who raised the child) included women who answered ‘don’t know’.

Nor does this prove that abortion regret is rare. A substantial minority of women feel they made the wrong decision, and most women even in very liberal Sweden say they would never have an abortion again. Around a third of women feel the emotion of regret, even though many of these feel they made the right decision. Feelings of regret regarding abortion are complex phenomena and cannot simply be reduced to feeling one might the right decision.

It is true, therefore, that most women feel they made the right decision in the years following an abortion (to my knowledge, there are no very long-term studies). But this number is significantly lower than 95%, and is actually lower than the proportion of women who were eventually be glad to be denied an abortion. Moreover, this is consistent with a significant proportion of women feeling emotions of regret and most women wishing never to have an abortion again.

Women suffer emotionally if they don’t get abortions

By now, we are in a position to respond to this claim. It is clear that abortion is not necessary to prevent clinical mental disorders, and in fact makes them worse. Recall that the RCOG say that ‘Women with an unintended pregnancy should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy’, while Fergusson concluded that ‘there is no credible scientific evidence demonstrating that abortion has mental health benefits.’ The lead author of the Turnaway study themselves admitted: ‘carrying an unwanted pregnancy to term was not associated with mental health harm… I expected that raising a child one wasn’t planning to have might be associated with depression or anxiety. But this is not what we found over the long run… Women are resilient to the experience… at least in terms of their mental health… women’s symptoms of depression and anxiety are slowly relieved following an unwanted pregnancy, regardless of how that pregnancy ends.’

But is abortion necessary to avert serious emotional distress short of mental disorder? Again, the evidence is pretty clear that the answer is no, not in general. Although it can easily be seen how a crisis pregnancy causes an initial panic, and abortion is the ‘great reliever’, the evidence that unwanted pregnancy causes lasting emotional harm is virtually non-existent (except in rare cases; but the same is true – more commonly – of abortion), and eventually almost all women are glad they continued the pregnancy. As we have just seen, a higher proportion of women denied abortions were glad to have been denied than the proportion of women who feel they made the right decision to abort. The Turnaway study also showed that life satisfaction was virtually identical between women who aborted and women who were refused abortions. The only significant difference was that women denied an abortion but who went on to have an abortion elsewhere (or a miscarriage) had marginally worse life satisfaction on average, a week after originally being denied an abortion. This did not last longer than a week in the study, however. Otherwise, life satisfaction was virtually identical between all the groups. Only 9% of women had poor maternal bonding, and even the overwhelming majority of these were still happy they had the baby.

Foster, the lead author of the Turnaway study, writes: ‘How do women feel about having been denied an abortion? Initially, bad. But over time, most of the women who ended up carrying the unwanted pregnancy to term reconciled themselves to their new reality, especially after their babies were born… Women don’t often say they want an abortion for fear of what an unwanted pregnancy would do to their mental health. And mental health rarely seems to suffer, even when abortion is denied… Most of the women turned away, over time, reported that they were happy they had the baby.’ She then goes on to describe the testimonies of women denied abortions and their feelings about their children: one started crying at the thought of not having her child: ‘She is just everything to me’; for another, the child was ‘terrifyingly bad timing’ but the mother was still ‘relieved that what happened happened… it breaks my heart that I actually thought about [having an abortion].’ Another described her life as crazy prior to becoming pregnant, with very little money, and she became angry at being denied an abortion. But she eventually said that having her child was ‘the best experience of my life’, making her a ‘better person’ and providing unparalleled intimacy. She said that she thought she would have died from drugs or recklessness if not for her baby.’

Although in some cases this coming to terms with the pregnancy can take some time, it often happens remarkably quickly. Even a week after abortion denial, only 65% of women still wished they could have an abortion, while 49% felt relieved. Only 12% still would have preferred an abortion by the time of the child’s birth. 27% of women who received an abortion felt happy about the pregnancy a week later, but 60% of those denied an abortion felt happy about it at the same time. A similar rare study on victims of rape found that over the course of the pregnancy, the average psychological state of rape victims improved dramatically across a wide range of outcomes. One recent study found that even just a pregnancy scare considerably increases the desire for pregnancy on average: women with a pregnancy scare were up to five times more likely to desire a pregnancy compared to their baseline. The authors suggested that the mere-exposure effect may be responsible for this finding. Another reason feelings about pregnancy may change so quickly is that pregnancy intention itself is not as binary as often thought: what are labelled unplanned or unwanted pregnancies often turn out to be highly ambivalent pregnancies.

In summary, there is no evidence that abortion is needed for either the mental health or ‘life satisfaction’ of women. There is evidence that abortion is worse for women’s mental health, however, and evidence that it has made women unhappier in other ways (see ‘How abortion harms women’).

What about the APA review?

The APA review claims that ‘among adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater than if they have a single first-trimester abortion than if they deliver that pregnancy’, conceding that ‘The evidence regarding the relative mental health risks associated with multiple abortions is more equivocal’.

The review initially claims that the question of whether abortion harms mental health is ‘not scientifically testable’. This is a strange claim which appears to render the conclusion of no association inevitable. The reasoning is that randomised experiments are not ethically possible. This is true, but does not mean that the question is untestable. It simply means that the very best kind of evidence is not available for this question. We can still have good evidence.

The review is also severely limited in scope; it is limited to single, first-trimester abortions in adults with unplanned pregnancies – thereby excluding the (overall) majority of abortions which occur either as one of many, in the second or third trimesters, in children, or in planned/wanted pregnancies. Indeed, these are widely acknowledged risk factors for mental health sequelae after abortion – but these women are entirely excluded from the study. The review’s conclusions, even if true, would be virtually irrelevant to the large majority of women seeking abortion. It even appears to concede a possible detrimental effect of multiple abortions.

Still, the review does provide a basis for its limited conclusion: two primary studies are highlighted as being of standout quality, Gilchrist et al. (1995) and Fergusson et al. (2006). Although Fergusson found that women having abortions had higher rates of mental disorder after adjusting for confounding factors, his conclusions were roundly dismissed owing to a few methodological concerns. Hence the conclusions were based on a single paper by Gilchrist. Gilchrist did find that deliberate self-harm was higher in women who had abortions and women who were denied abortions compared to women who chose to keep an unplanned pregnancy. However, this was only among women with no prior psychiatric history. Among those with previous psychiatric history, women denied an abortion had a far lower rate of deliberate self-harm than women who aborted, though the small sample size prevented any firm conclusions being drawn. Among women with prior non-psychotic mental illness, deliberate self-harm was much higher among women who aborted compared to both women who had an unplanned pregnancy and chose to keep the baby, and women who were denied abortions. Other than psychosis, for which no significant results were found, Gilchrist did not address other specific mental disorders, giving the study limited value for studying specific conditions.

Hence even conclusions based solely on Gilchrist’s study should have offered these more nuanced conclusions, rather than a blanket assertion of no association between abortion and mental health. Likewise, it should have said that there is no top quality evidence on anxiety, drug misuse, and alcohol misuse specifically, and hence remained agnostic on their relationship with abortion. I will comment more on the Gilchrist study in the NCCMH question below.

In fact, however, Fergusson published an updated and improved paper in 2008 which resolved the methodological concerns of the APA review, and found the same results: increased rates of a wide variety of mental disorders. For this reason, the 2011 NCCMH review rated Fergusson et al. (2008) as superior to that of Gilchrist, and the best study in existence. The APA review is therefore critically outdated—but by its own standards, a revised review would presumably have to follow the conclusions of Fergusson (2008)—that abortion is causally* associated with a diverse range of mental disorders. Fergusson estimated that abortion led to a 30% increase in mental disorders overall, and that 1.5-5.5% of all mental disorders among the cohort were attributable to abortion.

*Fergusson et al. give a number of arguments that the link is causal.

What about the NCCMH review?

The 2011 NCCMH review was considerably more thorough than the APA review and, crucially, included Fergusson’s 2008 study. It also refused to base conclusions on one paper: it performed a meta-analysis across the few best quality studies on each mental health outcome. These studies all compared women having abortions to women continuing unwanted or unplanned pregnancies – failure to include this comparison group ruled the study out of consideration.

It claimed, firstly, that Fergusson (2008) was indeed the best quality study in the whole field. At the time of writing, no study has surpassed it in quality (see below for comments on the Turnaway study and a more recent study by Steinberg et al.). So it is worth examining the precise conclusions of the NCCMH review, since they appear to differ from Fergusson’s.

Regarding anxiety, the meta-analysis found a 28% increase in anxiety for women undergoing an abortion, but since the confidence interval of the odds ratio marginally overlapped 1 (0.96-1.71), they concluded that there was insufficient evidence of an elevated risk – importantly, not that there was evidence of no elevated risk. The insufficient evidence was likely due to the small overall sample size, not a lack of association. This is confirmed by a fact unchallenged in the NCCMH report – that the only good quality study to address the risk of anxiety from multiple abortions found a statistically significant increased risk of 69%. This dose dependence argues in favour of a causal link, and of a genuinely significant link between single abortions and anxiety.

Fergusson (2008) was the only good quality study available on alcohol dependence. Although it found that the risk of alcohol dependence was seven times higher among women having abortions, the small sample size again prevented a statistically significant conclusion. Again, the evidence was deemed insufficient, not deemed to show a lack of association. The same is true of substance misuse, though in this case the risk was thirteen times higher in women having abortions. This prima facie association is entirely to be expected given the well-documented causal decrease in alcohol and drug use among pregnant women (the Turnaway study itself found that within a week of women being denied an abortion, drinking alcohol and binge drinking were massively reduced compared to women receiving an abortion, despite similar levels prior to seeking an abortion).

The results on suicidal behaviour and self-harm were more nuanced. In the meta-analysis, there was a clear association – explicitly concluded by the NCCMH – between abortion and suicidal behaviour, compared to continuing an unplanned pregnancy. However, the NCCMH claimed that when unwanted pregnancies were used from Gilchrist’s study – as defined by women who sought an abortion but were denied – the association disappeared on average between studies. Notably, the review only included women with no prior psychiatric history from the Gilchrist study – neglecting the fact that among women with a prior psychiatric history, rates of self-harm were much higher among women aborting than those with ‘unwanted’ pregnancies (i.e. denied an abortion). This skewed the NCCMH’s summary of Gilchrist’s study towards the null hypothesis. Again, the result on suicidal behaviour should be unsurprising, since pregnancy and motherhood are well-established strong protective factors against suicide (see ‘Does abortion harm mental health?’).

The review appeared to suggest that the lower rate of psychosis following abortion (from Gilchrist’s study) cancelled out the increased rate of suicidal behaviour, leading to no net difference. But Gilchrist’s study clearly stated that the findings on psychosis were spurious and that a better measure of psychosis found no disparity between the two groups. The NCCMH review appears to have misinterpreted the evidence on psychosis, leading to a misleading ‘balancing out’ of the risks of suicidality and psychosis.

The review found that overall levels of mental disorder were slightly higher in women aborting than women continuing an unplanned and unwanted pregnancy—but this did not meet statistical significance.

Hence, in summary, the NCCMH study should be interpreted not as concluding that abortion does not cause psychiatric disorder, but as concluding that the best quality evidence does suggest various associations, though these need to be confirmed with larger sample sizes. It also concludes clearly that multiple abortions are significantly associated with anxiety. Likewise, it demonstrates that abortion is worse for one’s risk of suicidal behaviour than choosing to keep the pregnancy, but it erroneously balanced this off against an illusory reduction in psychosis from abortion.

What about Gilchrist’s study?

The more controversial question is the NCCMH’s interpretation of the evidence on suicide. While it agrees that keeping an unplanned pregnancy reduces one’s risk of suicide compared to abortion, it suggests that when the pregnancy is unwanted (i.e. an abortion is sought), the evidence is more mixed, since Fergusson’s study is cancelled out by Gilchrist’s study. We have already seen that this conclusion involved erroneously omitting anyone with prior psychiatric disorder from Gilchrist’s data, but there are a number of other problems with treating Gilchrist’s study as equally informative to Fergusson’s:

1. In most Western countries, since abortion is generally legally available, the most relevant comparison is women choosing abortion with women with unplanned pregnancies choosing to continue pregnancy. Hence it makes no sense to dismiss the evidence regarding unplanned pregnancies as irrelevant. Women should be informed that, in the event of an unplanned pregnancy regarding which she may be ambivalent, the evidence supports her continuing with the pregnancy.
2. It is universally acknowledged that Fergusson’s study was better quality than Gilchrist’s, and the former showed an association between abortion and suicidality. To prioritise Gilchrist’s study, or even give it the same weight, would not do justice to the evidence. Gilchrist’s study also fails to cohere with the findings of the Turnaway study, which showed that women refused abortions who continued their pregnancies had no substantive negative mental health consequences, despite the study being biased towards this outcome (for reasons explained in ‘What about the Turnaway study?’).
3. There are a variety of concerns regarding Gilchrist’s methodology:
   • Unrepresentative sampling: the sample was selected from general practice, leading to a potentially unrepresentative sample (APA 2008).
   • High attrition rate: by the end of the study, only 34.4% of the abortion group remained, and 43.4% of the continued pregnancy group.
   • Follow up: it is unclear how reliable follow up was, since this relied on GPs having access to all diagnoses for women involved – which may not have been the case for certain hospital admissions.
   • Measurement of outcomes: likewise, the study has been criticised for not using any standardised measure of mental illness, relying on highly variable assessments by GPs (APA 2008).
   • Small sample size: these considerations are particularly important given the small sample size for the self-harm results: just 8 women who were denied abortions had self-harming episodes. As a result, the confidence intervals for women denied abortions and those obtaining abortions mostly overlapped – the increased rate was not statistically significant.
   • Miscarriages: it is likely that some women who were refused abortion ended up aborting the pregnancy elsewhere – those refused abortion had miscarriage rates about twelve times higher than those continuing the pregnancy. If so, then the group of women refused abortion will include some women who had abortions, whose negative outcomes would give a misleading impression of women refused abortion who kept the baby as a result. Women who keep their babies after being refused an abortion generally have significantly better outcomes than those who have an abortion elsewhere, even when their pregnancy intentions and ease of decision to abort are similar (note that this is another argument in favour of the causal effect of abortion, since the discrepancy cannot easily be attributed to women seeking abortions elsewhere being more desperate for abortions as a result of worse circumstances); even if not, however, women aborting elsewhere will artificially inflate the rates of mental disorders in the overall cohort unless separated.
   • Confounder control: the study has limited confounder control, in particular failing to note the particularly important confounder of social support. In the early stages of legal abortion in the UK, evidence suggests women were more likely to be denied an abortion if they had poor social support – and hence this group of women with poorer social support would be expected to have worse mental health outcomes regardless.
   • Unrepresentative: by the late 1970s, abortion was widespread in the UK and access to it may have been expected by women. Some of the negative outcomes from being refused an abortion may have instead been due to disappointed expectations and would not apply in a country or state where abortion is not expected to be available. Another sense in which it is unrepresentative is that it is unclear what pregnancy and childcare support was available to women denied abortion in the UK in the 1970s, compared with the significant support available publicly and privately in many countries, especially the US, in the contemporary setting.
4. As noted above, the analysis from the NCCMH excluded women with prior mental health difficulties. This group had lower rates of self-harm when denied abortion than women obtaining abortions, and is the group at highest risk for post-abortive mental health problems.

For all these reasons, it is implausible to suppose that Gilchrist’s results undermine Fergusson’s findings.

What did Fergusson’s meta-analysis show?

Following the NCCMH review, David Fergusson himself – by this time widely agreed to have led the best study on this subject – performed a meta-analysis, including a few more of the higher quality studies to increase the sample size and therefore probe whether the non-statistically significant associations identified in the NCCMH review were genuine associations or probabilistic artefacts. He found that when other good quality studies were included, abortion was associated with statistically significant increases in anxiety, alcohol misuse, illicit drug misuse and suicidal behaviour, compared to continuing an unplanned or unwanted pregnancy. These links persisted after a sensitivity analysis to eliminate the lowest quality studies.

Table 1. Odds ratios and significance levels from Fergusson’s (2013) meta-analysis. Significance levels are for two-tailed tests. Adapted from Fergusson et al. (2013).

Outcome	Odds Ratio	Confidence Interval	Significance
Anxiety	1.28	0.97-1.70	0.08
Depression	1.13	0.83-1.55	0.44
Alcohol misuse	2.34	1.05-5.21	0.04
Illicit drug use/misuse	3.91	1.13-13.55	0.03
Suicidal behaviour	1.69	1.12-2.54	0.01

Fergusson was himself pro-choice, and did not anticipate these findings. But he was committed to clinical accuracy regardless of politics, and said that while he thought abortion should be legal, it should not be performed on a false pretence of mental health, for which there is ‘no credible scientific evidence’. The latest meta-analysis, therefore, confirms that abortion is associated with anxiety, alcohol misuse, illicit drug misuse, and suicidal behaviour, even after adjustment for possible confounding factors.

What about the Turnaway study?

The Turnaway study compared women who received abortions with women who were denied abortions because they were over the gestation limit. While it has received a lot of media attention in recent years, has fatal methodological weaknesses:

1. It had a very low response rate and a very high attrition rate. By the end of the study, only 17% of those invited to the study remained (and the large majority refused to even join the study). Since women who have negative reactions to abortion are more likely to drop out (as the Turnaway study themselves found), this very depleted sample cannot be relied upon for conclusions about mental health.
2. The sample was not chosen randomly but seemingly chosen at the discretion of researchers. Only 58% of eligible women were approached for the study, with no explanation of why the others were not included.
3. The worse mental health outcomes among those denied an abortion were short term, and most importantly, only occurred among those who went to obtain an abortion elsewhere. Those women denied abortions who kept their babies had no worse mental health outcomes at any point. In fact, this is suggestive evidence that women who have abortions have worse outcomes than those who continue the pregnancy.
4. There is likely a selection bias, since women who are unaware of the gestation limit at their local abortion clinic and who haven’t checked eligibility several months into the pregnancy are more likely to be more disorganised, or perhaps more ambivalent, than women who present within the time limit. These sorts of factors are likely (or indeed proven) to be associated with worse mental health outcomes after abortion.
5. It has been reported that the authors of the Turnaway studies have refused to publish the questionnaire used, raising concerns about the selective publication and omission of important results.
6. The study provides minimal information about the support given to women who were refused abortion, so it is unclear whether these women were given the kind of support endorsed and offered by pro-lifers.
7. The measures of anxiety and depression used were extremely limited, consisting of only 6 questions each.
8. Finally, of course, as mentioned above, the same study, even if methodologically sound, still found that at least 96% of women denied an abortion who kept the baby were glad about it in retrospect – and 98% who didn’t place the baby for adoption.

In sum, the Turnaway study is of significantly lower quality than other studies on this topic and does not provide any reason at all to doubt our conclusions. Indeed, it even offers some limited data supporting our conclusions. See also Reardon’s response to the study.

What about Steinberg’s Lancet study on suicide?

A recent paper by Steinberg et al. is frequently cited to undermine what is now a relatively clear link between abortion and suicidality specifically. The study, using a large sample in Denmark, found that ‘women who had abortions had a higher risk of non-fatal suicide attempts compared with women who did not have an abortion. However, because the increased risk was the same both the year before and after the abortion, it is not attributable to the abortion’. There are a few problems with this study:

1. The study is not representative of women having abortions. It excludes women who have had previous abortions, women who have had previous suicide attempts, women having abortions after the first trimester, women having abortions at private clinics, and children. Thus it excludes many women with the highest risk of mental disorders following abortion.
2. Probably the most fatal problem with the study is that it does not include a comparison group of women with an unplanned or unwanted pregnancy. Thus, by the inclusion criteria for high quality studies in NCCMH, it would be automatically excluded on these grounds. This is reason enough to discard the study in favour of better quality studies. Ironically, Steinberg herself had previously criticised Fergusson’s earlier paper for not having a comparison group of women with an unintended pregnancy. But her new study does not even have a comparison group of women with any pregnancy.
3. The authors claim that because the suicide risk was the same before and after the abortion, abortion was not responsible for the (conceded) higher risk of suicide. This logic simply does not follow. Since pregnancy and childbearing are protective against suicide, the relevant comparison is with women continuing a pregnancy, not comparison with prior to an abortion. The comparison with women continuing a pregnancy is never made.

In fact, the study gives subtle evidence that abortion does increase the risk of suicide relative to pregnancy. In the month before the abortion, during which many women were aware they were pregnant, the suicide rate falls dramatically and seemingly anomalously. By contrast, after the abortion, the suicide risk goes immediately back up to baseline. This confirms the now well-established fact that abortion eliminates the protection that pregnancy offers against suicide. The study also notes that, in their sample (as in other research), women having given birth to a child had a significantly lower suicide risk than women who had not.

4. Finally, the discussion in the paper makes straightforwardly false claims about previous studies, claiming that ‘Other research has not found significant associations between abortion and suicidal ideation.’ As we have seen, this is simply untrue. The study entirely whitewashes the history of study on this question, not even citing Fergusson’s seminal 2008 paper, widely agreed to be the highest quality study on this topic.

For these reasons, the study is profoundly discreditable. Reputable journals can sometimes publish very poor or discreditable research. The Lancet itself has done so on numerous occasions. This is certainly not a reason to dismiss everything they publish – but it does warrant a healthy scepticism and critical attitude towards some literature published therein.

How common is ambivalence before an abortion?

Ambivalence before abortion is very common. As explained in ‘95% of women having abortions feel they made the right decision’, research from Major and Fergusson shows that between 11-30% of women did not feel they made the right decision after an abortion – and this number may increase over time.

In the Turnaway study, 27% of participants found the decision ‘very difficult’, and a further 27% ‘somewhat difficult,’ even despite a possible selection effect whereby women finding the decision difficult refused to participate; the authors note that women who felt less relief and happiness at baseline were more likely to be lost to follow up.

Husfeldt et al. found that 30% of women were still in doubt about their abortion 2 days beforehand. Rocca et al. found that within a week of being denied an abortion, 6% already said they didn’t know whether they wished they could still have an abortion, while 35% said they did not wish they could still have an abortion. In Sweden, Soderberg et al. found that 12% of women seeking abortion decided to continue the pregnancy in the end, with Holmgren and Uddenberg arguing that the rise of medical abortion in Sweden reduced decision-making time and exacerbated the problem of hasty ambivalent abortions. BPAS, the leading abortion provider in the UK, reports that 16% of women seeking abortion there end up having their baby, even though at other abortion providers women are encouraged to proceed with abortion regardless of their ambivalence. Likewise in the UK, 3% of women said they considered continuing the pregnancy right up until the night before the abortion.  In Norway, 15% had not decided to have an abortion before seeking out abortion services. Early literature in the UK showed that of 7,110 women seeking abortion, 4.5% decided against abortion in the end, and a further 5.3% were denied. Among those with a failed medical abortion and continuing pregnancy in the UK, 10% decided to continue with the pregnancy in the end. In the major study on abortion pill reversal, 754 patients sought abortion pill reversal, and 8% of those seeking abortion reversal ended up having an abortion again, along with up to 15% lost to follow up. Practitioners in the UK claim that 90 women have sought abortion pill reversal in a one year period.

As pro-choice reproductive health scholar Sam Rowlands puts it:

“It is well known that women requesting abortion do change their mind. Change of mind is correlated with the degree of ambivalence. All abortion providers see occasional cases of women backing out at the last moment, even in the anaesthetic room.”

See also ‘How common is coercion?’

Summary of abortion and mental health

In short, we know the following with considerable confidence:

1. Abortion is causally associated with increased rates of suicidality, drug and alcohol misuse, and anxiety. Multiple abortions appear to increase the risk substantially more.
2. Abortions-specific post-traumatic stress disorder is a common to very common complication of abortion, affecting somewhere between 1.4-14.3% of women obtaining abortions – equating to at minimum 10,000 women in the US every year, for example.
3. The large majority of women obtaining abortions feel guilt, sorrow, sadness and disappointment following an abortion, even though most also feel relief. A substantial minority of women feel guilt even many years later.
4. Most women feel they made the right decision to have an abortion. However, a substantial minority (up to 30%) did not feel they made the right decision, and most say they would never want to go through an abortion again. There is some evidence that decision satisfaction decreases over time.
5. When denied abortion, women quickly come to terms with the pregnancy and almost always are glad about it by the child’s 5^th birthday. 98% of women denied abortions who raise the baby are glad they were refused an abortion by the child’s 5^th birthday, and 85% of women denied abortions who placed the child for adoption were glad (even just one week after being denied an abortion, only 65% of women still wished they could have an abortion). Only 9% of women denied abortions had poor maternal bonding, and the overwhelming majority of these were still happy they had the baby.
6. Ambivalence is very common among women obtaining abortions, with only 65% of women denied abortions wishing they could still have one just a week later.
7. While external stigma contributes to these negative mental health outcomes, it cannot fully explain the association between them, and even if it did, it may be ineliminable.
8. There is no evidence that women denied abortions, on the whole, experience negative emotions or mental health as a consequence.
9. Abortion may be responsible for around 1.5-5.5% of mental disorders in a given cohort of reproductive age women.

All this is particularly important since suicide is the leading cause of maternal death in the developed world; it is partly for this reason that mortality following abortion vastly exceeds mortality following completion of a pregnancy. Typically, while maternal mortality statistics include deaths from suicide after pregnancy, abortion mortality statistics do not; this is one of the numerous reasons to be sceptical of claims that abortion is safer than childbirth.

What are the policy implications?

In light of this evidence, there is a good case for informed consent laws ensuring that women are properly informed about potential mental health consequences of having an abortion, prior to doing so. Women should also be screened for risk factors of negative psychological outcomes (this is already widely recommended, for example by the Royal College of Psychiatrists and the NCCMH review, and yet still not routinely implemented), with the risk factors being well-known. Moreover, doctors should generally refuse abortions on clinical grounds, even if abortion on demand should be available as a non-clinical intervention. Routine psychological follow-up could be justified, and psychological support after abortion should at least be expanded, given widespread concerns that, while it is easy to obtain an abortion in the UK, post-abortion support is severely lacking, especially in the case of disability-selective abortion. There is a case for limiting abortion to protect women’s mental health, either by limiting it to exceptional circumstances or more limited interventions, like mandatory waiting periods. Elective abortion should not be considered in any way healthcare (whether in terms of public funding or otherwise).

More research would also be most welcome. Contrary to popular representation, which cites the NCCMH review as the decisive evidence showing abortion is not associated with poorer mental health outcomes, the most claimed by the NCCMH review is simply that the evidence was very uncertain for every outcome. It is puzzling, therefore, that the review recommended diverting research away from this question. It can only be reasonably concluded that some working in this field do not want an answer – or perhaps are scared of the answer. The censorship experienced by David Fergusson – himself pro-choice – is perhaps an indicator of why.

Do pro-life laws work?

How many abortions occur when abortion is illegal?

Does welfare reduce abortion?

Does sex education reduce abortion?

Does contraception reduce abortion?

Democrat Presidents reduce abortion rates more than Republican Presidents

Do pro-life laws work?

There is a common claim that banning abortion is pointless because it doesn’t work. Women will get abortions anyway; indeed, they will get unsafe abortions and die as a result. I deal with the latter claim under ‘Does legalising abortion prevent women dying from backstreet abortions?’

It is worth noting that this same argument was used in support of the slave trade. It was argued, for example, that keeping the slave trade legal would allow it to be better regulated, and hence allowing better conditions for the slaves on ships, for example. Abolitionists were often blamed for uprisings in which many people were killed, because they had allegedly stoked tensions by giving slaves the hope of freedom. All of us find the pro-slavery arguments unconvincing for two reasons: a) even if they were empirically correct, the dignity of human beings kidnapped and trafficked into slavery deserved to be recognised in law; and b) it is profoundly implausible that the empirical claims are correct.

The same is true in this case. Take the empirical claims, for example. In fact, there is no serious controversy about whether giving legal protection to unborn children reduces abortion rates. Although some otherwise credible people sometimes repeat this claim, there is in fact no evidence for it at all. By contrast, there is overwhelming evidence that pro-life laws do work, even though they don’t entirely eliminate abortion (just as no laws entirely eliminate the crime).

It would be somewhat tedious to list all the evidence that pro-life laws reduce abortion rates here, though I am working on a paper to that effect. For those who are sceptical, Secular Pro Life have put together long lists of studies supporting this conclusion here and here. Philip Levine’s Princeton University Press book Sex and Consequences is also highly recommended.

But for perhaps the most direct and clear evidence, consider the Turnaway study, where women seek abortions, are denied because they are over the gestation limit, and go on to either have an abortion elsewhere (illegally or out of state), miscarry, or have the baby. This study provided incontrovertible evidence that pro-life laws work: of women turned away from the clinic, over 2/3 went on to have the baby, with most raising the child themselves and a small minority placing the child for adoption. Moreover, a variety of such ‘turnaway’ studies have been done historically and recently. The lead author of the study – a passionate pro-choice advocate – wrote an article summarising some of the evidence that pro-life laws work and pleading with fellow pro-choicers not to keep making this claim.

The only evidence usually cited for the claim that pro-life laws don’t work is a couple of studies in The Lancet which show that countries with pro-life laws have similar abortion rates to those with pro-abortion laws. Some of the problems with drawing such conclusions from these studies are, to be candid, obvious. Others are less so. In short, the problems are:

1. The methods used to estimate abortion incidence in pro-life countries unreliable, for obvious reasons. The standard method used for estimation, the Abortion Incidence Complication Method, is critically analysed under ‘How many abortions occur when abortion is illegal?’
2. Secondly, the studies do not control for any possible confounders, and hence insofar as they are interpreted to claim that there is no causal relationship, they commit the correlation-causation fallacy. There are clearly many other differences between pro-life and pro-choice countries which could explain higher abortion rates in the former – for example, much higher rates of poverty and much lower access to reliable contraception. When like countries are compared with like (as with the UK and Ireland/Northern Ireland), it is clear that pro-life countries have far lower abortion rates. This is a very obvious and fatal problem with the conclusion, which would probably be noticed by an astute child.
3. Finally, the studies themselves point to a more salient statistic: the proportion of pregnancies ending in abortion was much higher on continents with primarily pro-choice laws. For example, the most recent study explicitly notes: “In the group of countries where abortion is prohibited altogether by law or allowed only to save a woman’s life, 48% of unintended pregnancies ended in abortion… this proportion was substantially higher, at 69%, in countries where abortion is allowed on request”. The same trend is true when all pregnancies are considered, not only unintended pregnancies.

Hence there is no remotely persuasive evidence that pro-life laws don’t work, and an abundance of evidence that they do. There is no reasonable controversy on this question.

How many abortions occur when abortion is illegal?

Obviously, no one knows for sure. Abortions are generally massively underreported when women are asked directly, even when entirely legal and more so when abortion is illegal. But this is an important question for which we should understand the evidence commonly cited, since claims about illegal abortions are often used to argue for abortion legalisation: for example, that abortions are very common anyway, or that abortions cause a huge economic burden on the healthcare system, or that many women die from illegal abortions (these arguments are dealt with separately).

There is one particularly common method used to estimate abortions where abortion is illegal: the Abortion Incidence Complication Method. This involves clinics and hospitals estimating how many women they see per month with post-abortion complications. Since many of these women are having miscarriages, an estimate is used of women obtaining medical care for miscarriage complications. This is based on (among other assumptions) the idea that women will only seek medical help for miscarriages after about 13 weeks of pregnancy, and that these are about 3.41% of live births. This figure is subtracted from the total number of estimated post-abortion complications to yield the complications due to illegal abortion specifically. Then, another estimate is given of the proportion of illegal abortions requiring medical treatment – if 20% of illegal abortions are thought to need medical care, then the estimated complications from induced abortion are multiplied by 5 to reach the total number of abortions. Most of these involve guesswork, as is often conceded in the studies themselves.

The logic is perfectly sound, but there are a number of critical flaws. These are comprehensively addressed in a forthcoming paper by a colleague (please ask for details), but here are a couple of the key issues:

1. The method relies on a very low estimate for miscarriages requiring medical attention – 3.41%. In fact, it is known that the number is significantly higher in countries such as the UK (up to 7.8%) and Ireland (7.8% from personal correspondence with the author, when late miscarriages are included). In many countries with pro-life laws, there are significantly more risk factors for miscarriage, such as ethnicity, malaria, malnutrition, being underweight, and HIV infection. A more plausible estimate of miscarriage prevalence alone radically reduces the estimate of abortion complications and abortions. For example, assuming 1 million live births a year, 100,000 ‘abortion’ complications presenting to hospital, 80% of miscarriage complications needing treatment actually getting treatment, and miscarriages needing treatment totalling 3.41% of live births, you get an estimate of 72,720 complications from induced abortion in hospital each year. Changing 3.41% to 7.8% yields an estimate of only 37,600 complications from induced abortion in hospital each year. Changing to 10%, given a likely higher rate of miscarriage in developing countries (10% being used for illustration), yields only 20,000. Hence the estimates depend critically on this figure, and 3.41% is an entirely implausible assumption.
2. This method therefore yields entirely implausible results. For example, applying this method to known data in the UK from 2002-2003 regarding miscarriage complications yields the result that 57% of women presenting to hospital in the UK with miscarriages are in fact presenting with complications of induced abortion – around 25,000 in fact. This is absurd in light of the fact that virtually none of these women have had induced abortions.
3. A similar example is given by Elard Koch. The method generated an estimated 165,000 abortions in Mexico City annually before legalisation in in Mexico City in 2007. But as Koch points out, in the year following legalisation, only 10,137 abortions were recorded in Mexico City, and the total number of abortions over a five year period following legalisation was 78,544, less than half the AICM estimate for one year alone – and this is after a likely significant increase as a result of legalisation. Either the method is wildly inaccurate, or the overwhelming majority of abortions remain illegal and potentially unsafe even after abortion is legalised (or both). Neither are promising options for those advocating abortion legalisation.
4. It is perhaps unsurprising in light of this that the Guttmacher Institute, from which this method mainly derives, admit: “If our assumptions about the likelihood that women seek such care [for miscarriage] are inaccurate, our abortion estimates will be as well”. The above evidence demonstrates conclusively that these assumptions are indeed incorrect.

The Royal College of Obstetricians and Gynaecologists themselves noted in 1966 that high estimates of illegal abortion in the UK prior to legalisation were wildly inflated: ‘It has been repeatedly stated that as many as 100,000 criminal abortions are induced in this country each year, and a more recent estimate is 250,000. These, and an earlier figure of 50,000, are without any secure factual foundation of which we are aware.’ They even noted explicitly that the majority of complications they saw (at least 80%) were, in fact, from miscarriages, not abortions. By contrast, a more sober estimate in 1964 suggested around 10,000 illegal abortions a year. England and Wales now have over 200,000 abortions a year.

Does welfare reduce abortion?

It is easy to see why one might think more welfare would reduce the abortion rate: a significant number of women cite financial concerns as a reason for abortion. So, alleviating those financial concerns might help them to continue the pregnancy.

Unfortunately, the empirical evidence on welfare is far more mixed, demonstrating minimal impact or occasionally conflicting results. One explanation of conflicting results is that welfare has different effects in different contexts. This appears to be true in the case of abortion.

It appears that welfare modulates and amplifies a jurisdiction’s general position towards abortion, at least in the much-studied US context. That is to say, in pro-life states which discourage abortion, welfare is indeed associated with reduced abortion rates. But in pro-choice states with minimal limitations on abortion, welfare is associated with increased abortion rates, meaning that pro-choice pro-welfare parties are not only worse than pro-life parties, but (with respect to abortion rates) even worse than a pro-choice anti-welfare party. The point is: without a pro-life cultural and policy context, welfare appears to be not only ineffective, but even counterproductive.

Evidence from outside the US is consistent with this picture. European countries with the most maternal leave and most generous overall family/gender policies have abortion rates significantly higher than the European average, especially the Nordic countries. And while abortion rates in the developing world are highly controversial/unreliable, it is uncontroversial that a far lower proportion of unwanted pregnancies in low income countries result in abortion compared with high income countries.

There are a variety of explanations for this phenomenon. For example, finances are a relatively uncommon reason for abortion, especially in low income countries. Second, most women who cite financial concerns also cite other reasons for abortion, so that alleviating these concerns will not necessarily make the pregnancy acceptable. Third, only a tiny proportion of women consider financial support relevant to their decision, and most say that nothing could have changed their decision. In the US, only a small minority of women said that they would make a different decision given a European-style safety net. These and other reasons explain why the empirical evidence for welfare improving abortion rates is very limited.

Does sex education reduce abortion?

Perhaps by definition, good sex education reduces abortion – since part of what makes sex education good is that it results in fewer pregnancies likely to end in abortion. The question most people have in mind for political reasons is: does the sex education typically offered in public schools reduce abortion rates? Again, the rationale is intuitive, but the empirical evidence is virtually non-existent.

Systematic reviews of randomised control trials from the prestigious Cochrane database have found no impact of sex education interventions on teen unintended pregnancy rates. In fact, the only randomised controlled trial which did show a significant reduction in teen pregnancy – with a massive effect size of 80% – was from a much-derided abstinence programme. More recent cross-country evidence has found an increase in teen pregnancy and abortion rates from sex education mandates, mitigated by allowing parents to opt their children out.

Again, this seems counterintuitive to many people. As Paton, Bullivant and Soto point out, however, sex education can have mixed effects: it can reduce the likelihood of a given instance of sexual intercourse resulting in pregnancy (through encouraging contraception), but can also increase the rate of ‘uncommitted’ sexual intercourse more generally (through removing fears of pregnancy, normalising extramarital sex, etc.). Hence, the effect of sex education is inherently mixed and can only be discerned by engaging the actual empirical evidence. When that is done, there appears to be no convincing evidence that typical sex education works – though some limited evidence that abstinence education works.

Does contraception reduce abortion?

One thing is obvious, so no one may interpret me as saying otherwise: contraception clearly reduces the risk of pregnancy in a given instance of sexual intercourse.

The relevant question, therefore, is whether contraception promotion a) leads to fewer unintended pregnancies, and b) affects the likelihood of an unintended pregnancy being aborted. These are separate questions. Regarding the latter, contraception may increase the likelihood of an unintended pregnancy being aborted, since it cultivates a culture where pregnancy is seen as only an optional outcome of sex (in other words, it makes pregnancies more likely to be unwanted, as explained by John Cleland).

Regarding the former, the same considerations apply as in the case of sex education: namely, contraception can decrease the cost of risky sex and thereby incentivise it. This may compensate for or even outweigh any decrease in pregnancies from using contraception in a given instance. In fact, there is clear empirical evidence that contraception increases risky sexual behaviour. Since contraception failure rates are significantly higher than most people realise (leading to half or more of all abortions in many countries), it may well be that the increase in risky sex outweighs the decrease in pregnancy-per-intercourse.

It is known that abortion rates are still very high even where contraceptive access is close to perfect. Indeed, Northern Europe, which has extremely good access to contraception (and has for many years), has particularly high abortion rates, indeed, some of the highest in the world.

Examining the empirical evidence in detail shows no consistent pattern between contraceptive availability and abortion. No study on emergency contraception to date has shown a reduction in abortion rates. A recent systematic review found no effect of contraceptive-promoting interventions on reducing adolescent pregnancy. Abortion rates increase with increased contraception just as often as they decrease, and those countries which do see an inverse correlation tend to be exceptional cases where abortion is already extremely widespread as a means of contraception, e.g. the former Soviet countries. Even where there is an inverse correlation, the effect size is still relatively small. Many studies looking at particular contraceptive access programmes show no effect on abortions or teen pregnancies, in some cases even showing a long-term increase.

Finally, it is worth noting that the contraception whose widespread use is most likely to cause a decrease in abortions – namely, the more effective long-acting reversible contraception – may itself be abortifacient at times, which would be the reason it is so effective in the first place. So for a pro-lifer the use of such contraception would be questionable (though the empirical evidence is still somewhat unclear).

It is clear that contraception promotion as a policy does not reliably reduce abortion rates because of these offsetting factors. But even if it did, it is not clear that this should be particularly salient politically. In fact, when the US President changes, there is in general no change in contraception use either in the US or overseas (see supplementary material, figure 4). Even in developing countries, unmet need for contraception is only 12.8% (it is 5.9% in the US). This is a small figure, but some might think that contraception availability might address that 12.8% and significantly reduce the abortion rate as a result. However, it turns out that only 4-8% of that 12% – that is, 0.48-0.96% of sexually active women of reproductive age – gave ‘lack of access’ as a reason for not using contraception. Generally, it was the choice of the women not to use it. Hence it is very difficult to believe that increasing access to contraception would have a very large beneficial effect on the abortion rate. Contraception access is relatively politically insignificant in comparison to pro-life laws.

Democrat Presidents reduce abortion rates more than Republican Presidents

As a piece of evidence for the above objections – that welfare, sex education and contraception reduce the abortion rate more than legal protections for unborn children – it is sometimes claimed that abortion rates fall quicker under Democrat Presidents than under Republicans. I write this response not out of any particular fondness for the Republican Party, with which I have deep disagreements on economic and environmental issues, among other things. But insofar as this claim is used to confirm the idea that welfare, sex education and contraception promotion work better than legal protections for unborn children, it is worth responding to.

Graphs like the following are normally shown:

The claim is that abortions increased under Ford (R) and Carter (D), plateaued under Reagan (R) and Bush Sr (R), decreased under Clinton (D), decreased more slowly under Bush Jr (R), and decreased more quickly again under Obama (D).

The biggest problem with such a claim is that the federal government, and even more so the President, have only a very small, or even non-existent, short-term impact on abortion rates, since Roe v Wade forces states to allow abortion, and the Senate filibuster (requiring a supermajority) means no significant pro-life legislation can pass at a federal level. And of course, for many of these years, the President had not even a Senate majority, let alone a supermajority. Ford had a Senate minority for all 4 years (and Nixon likewise before him), Reagan for 2 out of 8 years, Bush Sr for all 4 years, Clinton for 6 out of 8 years, Bush Jr for 4 out of 8 years, and Obama for 2 out of 8 years. Given that virtually all domestic pro-life or pro-choice legislation requires a Senate supermajority, along with Roe v Wade, the President has very little power to do anything domestically. The main things they can do are a) support or discourage abortion overseas, and b) appoint Supreme Court Justices. Obviously the former will not show up in domestic abortion rates, and the latter will have only a very long-term impact, given how long it takes to fundamentally change the composition of the Court. Hence, for example, it is likely (at the time of writing; January 2022) that Roe v Wade will be overturned under President Biden, a Democrat. This is obviously despite a Democrat President, not because of him.

This also holds a clue to the large drop in abortions under President Clinton. As can be seen from the graph, the large majority of the drop came at the very beginning of the Presidency (1993), with the rate then decreasing at a fairly average rate. But this was just after the 1992 Supreme Court judgment Planned Parenthood v Casey which, while upholding the legal right to abortion, allowed unprecedented regulations on abortion, such as informed consent laws, waiting periods, parental involvement laws, and reporting requirements, at a state level. Studies have shown repeatedly that these sorts of state laws reduce abortion rates. Again, clearly these laws were allowed to be implemented despite a Democrat President, not because of him.

This is an example of more fundamental problems with the original claim. There are simply too many other factors – most of which are irrelevant to the President – to make this sort of crude association. Under Ford, abortion had just been legalised nationwide by the Supreme Court, so this is clearly responsible for the big uptick in abortions, which continued under Carter. Reagan and Bush Sr appear, if anything, to have flattened out the sharp rise, and so can hardly be faulted for not reducing it as well, when the natural trend was sharply upwards. Clinton coincided with Planned Parenthood v Casey, and also implemented welfare reform which made welfare law much stricter, so the reduction in abortions can hardly be attributed to more welfare under a Democrat President! In some presentations of this data there are even more obvious problems: some graphs (depending on the source) show a big drop in the 1990s under Clinton which is simply due to the fact that California stopped reporting its 200-300,000 abortions per year in the late 1990s.

It does appear to be true that the rate fell faster under Obama than under Bush, but this is a very small sample size with Presidents who could do very little about abortion. Indeed, the start of Obama’s term came shortly after the Supreme Court upheld the partial birth abortion ban (2007), which coincided with a spike in pro-life public opinion. It is difficult to draw any conclusions either way here.

Given that the overwhelming majority of abortion legislation comes at a state level, what is far more telling is the state abortion rate. Below is a graph I put together with data from the Guttmacher Institute’s Data Center (the GI being the research arm of Planned Parenthood). States are colour coded by state legislature: red for Republican, blue for Democrat and yellow for divided. Three things can easily be seen: a) whether a state is red or blue does not affect its contraceptive prevalence; b) contraceptive prevalence seems to have minimal overall correlation with abortion rate; and c) there is a very clear difference in abortion rate between red and blue states – and the differences are enormous, with Republican states typically having abortion rates between 5-10 with a few higher, and Democrat states being fairly evenly distributed between 10-30 (and none below 10). Since states have far more power over abortion policy than the federal government, and even more so than the President, this seems to be a far better measure, and if anything would clearly indicate that pro-life laws are far more effective than the proposed alternatives to reduce abortion rates.

This is confirmed by the fact that European countries which have had very strong welfare systems, free contraception for many years, and widespread sex education in schools, such as France, the UK, and Sweden, still have significantly higher abortion rates than the US.

Of course, even this does not take into account confounding factors, though the correlation is impressive. Most telling, of course, is the rigorous studies we have simply showing clearly that legal protections for unborn children do, in fact, reduce the abortion rate, while welfare only does so in the context of legal protections, sex education does so only when it encourages delaying sexual debut, and contraception promotion does so (generally) only when abortion is already widely used as birth control (and perhaps a few other exceptional circumstances). See the questions on these above.

Finally, it is worth noting that the other main contribution Presidents can make is through foreign and aid policy: encouraging other countries to legalise abortion, or donating money to organisations which lobby for, or even provide, abortions in developing countries. Given the evidence seen above, it is clear that other countries legalising abortion will drastically increase the abortion rate in them, as has been seen in almost every country which has ever legalised abortion. It is pretty uncontroversial that Democrat Presidents encourage other countries to legalise abortion, and Republican Presidents encourage them not to. Likewise with money donated to abortion lobbying organisations such as Planned Parenthood and Marie Stopes.

There has been one challenge to this claim, however: it is claimed that a 2019 paper by Brooks et al. demonstrates that the Mexico City Policy (which bans US aid funding going to any organisation which performs or promotes abortion overseas) has a counterproductive effect. It is alleged that by reducing contraceptive prevalence (by defunding family planning organisations), the abortion rate is paradoxically increased. There are a number of problems with attempts to draw these conclusions from this paper.

1. The paper doesn’t take into account changes to the law, because these are far rarer and more discrete. This has an enormous impact on abortion prevalence, and is far more likely to occur under American pressure under Democrat governments.
2. Only a tiny minority of women in developing countries lacked access to contraception by 2008, the end of Bush’s tenure. As explained in ‘Does contraception reduce abortion?’, only around 0.48-0.96% of women in developing countries were not using contraception due to lack of access in that year. Given that some women will also lack access to abortion under Democrat governments, it is profoundly implausible that this small change in access could increase abortion rates by the 40% alleged by the authors.
3. Contraceptive prevalence is, in fact, not affected at all by the single Republican government examined in the study. The figure shown is taken directly from the study, and shows countries strongly affected by the Mexico City policy in turquoise and countries not strongly affected in orange. In both sets of countries, contraceptive prevalence continued increasing under Bush Jr, at about the same rate as it was increasing under Clinton previously. In fact, the only different trend observable is that in the middle of the Bush administration, contraceptive prevalence rapidly accelerated far beyond the rate of increase under Clinton. This increase plateaued again under Obama. Indeed, though countries affected by the MCP had significantly lower contraceptive prevalence at the start of Bush’s tenure than countries not affected by it, by the end of Bush’s tenure countries affected by the MCP had almost caught up. Hence, if anything, the study seems to show that contraceptive prevalence increased at a greater rate during the implementation of the Mexico City Policy.

4. It is independently known that funding restrictions have a huge impact on lowering abortion rates. The Guttmacher Institute’s own literature review shows that cutting Medicaid funding for abortion prevents a massive 18-37% of abortions, with the best study suggesting 37%.

5. By contrast, it is independently known (see ‘Does contraception reduce abortion?’) that contraception promotion has at best a mixed effect on abortion rates.

6. In countries not affected by the MCP, the abortion rate was very high but quickly decreasing under Clinton and Obama, and bottomed out under Bush in between (see picture). In countries affected by the MCP, abortions were steadily increasing under Clinton, plateaued under Bush, before dramatically increasing again under Obama. The clear trend is that in both sets of countries, abortion rates were significantly lower under Bush (except insofar as a trend of slight increased continued under Bush from Clinton in MCP countries). Obama’s presidency corresponded with a dramatic and fairly immediate spike in the number of abortions, despite contraceptive prevalence increasing during that time.

7. These fairly clear trends are obscured by the methodology employed the authors, which used the non-MCP countries (orange line) as a control, such that any deviation from the same trend in the MCP countries (turquoise) is interpreted as resulting from the imposition (or not) of the Mexico City Policy. But this methodology is only appropriate when the control and intervention groups are relevantly similar and can be expected to follow the same trends. In short, the difference-in-difference methodology assumes that the trends in both groups will be exactly parallel apart from the intervention studied. But the graph itself shows that this is an impossible assumption. Non-MCP countries started with an abortion rate around three times the rate of MCP countries. Non-MCP countries were rapidly decreasing, so quickly in fact that for MCP countries to follow the same trend, MCP countries would end up with a negative abortion rate – which is obviously impossible. The two groups are completely different and had completely different natural trajectories: it follows that the methodology employed by the authors is wholly inappropriate and should not have been used.

For all these reasons, the claim that the Mexico City Policy increases the abortion rate by reducing contraceptive prevalence has no reasonable empirical basis at all.

In summary, the available evidence suggests that, in fact, Republican governments are far more likely to reduce abortion rates – as reflected most clearly in state abortion rates – than Democrat governments. This is not to offer any comment on the parties more generally. Rather, it is to dispel the notion that legal protections for the unborn are less important for reducing abortion than other measures such as contraception, sex education and welfare.

What does international human rights law say?

Should abortion be illegal?

Should women having abortions go to jail?

Should women having miscarriages be investigated for murder?

Is it reasonable vote based on abortion alone?

What does international human rights law say?

Opponents of the right to life often claim that abortion is a human right, and that ‘the UN says so’. Neither of these are true. While some UN agencies and treaty bodies with no legal authority often advocate for abortion against the explicit position of many of their member states, UN member states have always been very clear that abortion is not a human right – in fact, they have often said the opposite, that abortion is a violation of the human right to life.

At least 3 major international agreements enshrine protection for unborn children.

The International Covenant on Civil and Political Rights, a legally binding treaty, states clearly:

“1. Every human being has the inherent right to life. This right shall be protected by law.” (Article 6)

If unborn children are human beings – which, as we have seen, is proven by science – then in international law they have a right to life which requires legal protection. This right is not violable even ‘In time of public emergency, which threatens the life of the nation’ (Article 4). The ICCPR also forbids capital punishment specifically for pregnant women, recognising that unborn children need extra legal protection.

The Convention on the Rights of the Child, another binding international treaty, re-affirms this right to life of every child (Article 6) and states that:

“States Parties shall ensure to the maximum extent possible the survival and development of the child” (Article 6)

It also makes explicitly clear that childhood begins before birth:

“the child, by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth” (Preamble)

Finally, the agreement signed at the International Conference on Population and Development, while not legally binding, is an important document containing consensus positions adopted by 179 governments. It states:

“Governments should take appropriate steps to help women avoid abortion, which in no case should be promoted as a method of family planning”. (7.24)

It also requires governments to “reduce recourse to abortion”. (8.25)

Countries are bound by international law to protect the right to life of all human beings, including children before birth, and bound by political agreement not to promote abortion as a method of family planning, as well as to take steps to help women avoid abortion. Legalisation of abortion is the exact opposite of these commitments.

Should abortion be illegal?

It is common to think of the law as punitive: punishing people who do the wrong thing. It is also common to think of the law as restrictive: as the state interfering to stop people from living their lives in the way they want. With these ideas about the law, it is easy to see why some people object to a law prohibiting abortion. No one wants to see people punished. No one wants the state to interfere in the lives of others unless absolutely necessary. Hence some people think that although abortion is wrong, it should not be legally prohibited.

I think these characterisations of the law are unfair; they do not highlight the central, good purpose of good law: to defend and protect the most vulnerable members of society. All of us want some laws: we all recognise how easily innocent people can be harmed, even with the best of intentions. And so we all recognise the need for the law to protect ourselves, and especially to protect the most innocent.

This is why international law speaks in such clear terms about the rights of every single human being, no matter their size, their level of development, their gender, race, or their abilities. It states clearly (see above) that “Every human being has the inherent right to life. This right shall be protected by law.”

This says two things: firstly, that the protection afforded by the law belongs to every human being. And secondly, that it is not enough to believe in the right to life privately or personally: it says explicitly that the right to life needs to be protected by law. Without this, there is no substantive right to life.

Martin Luther King Jr. said that “The law cannot make the white man love me. But it can stop him from lynching me.” The law does not always change hearts and minds – though it certainly can do to a large degree. But pro-lifers do not oppose abortion because they don’t like it, as if it were mere preference. Nor do they think that prohibiting abortion will make everyone love and respect unborn children. But the law does protect them, just as it protects everyone else from being killed, however much they might be hated. Because unborn children are equal human beings with equal rights, they should have equal protection in the law. Since other human beings have legal protection against being killed, so should unborn children.

Should women having abortions go to jail?

It is sometimes claimed that for the pro-life view to be consistent, it should advocate for women who have abortions to be jailed. This, it is claimed, is a horrific conclusion, so as to render the pro-life position absurd. It is worth noting to begin with that the mainstream modern pro-life movement is generally united in opposing retributive punishment for women obtaining abortions. Hence, examination of the many Bills prohibiting abortion in various US states shows that women are always exempted, usually with an explicit provision to this effect. In many countries, even when there is a punishment prescribed for women having abortions, this is never implemented in practice, as in Malta (despite hundreds of abortions there each year).

Laws can always be framed in two ways: restricting or punishing the culprits, or protecting the victims. They will inevitably sound more negative when framed as punitive. But the point of them is ultimately to protect the vulnerable. As international law dictates, every human being’s right to life must be protected by law – meaning that there must be a legal prohibition on anyone violating that right.

Still, there are many different ways you could protect the unborn child in law without punishing the mother – perhaps by punishing doctors (e.g. removal of their licence) and thereby making abortion less accessible.

My personal view is that I don’t want to see anyone go to jail. I am also opposed to retributive punishment for those who are truly remorseful and at low risk of harming others in the future. I am opposed to retributive punishment for women obtaining abortions.

Still, this doesn’t answer the central question: aren’t I inconsistent or insincere for not wanting women to be punished, if I really think abortion is as serious as I say?

A helpful place to start in setting our intuitions is the question of infanticide. Should women go to jail for infanticide in some cases? In all cases? How should we decide? If you think they should go to jail in some cases of infanticide, why shouldn’t they go to jail for late-term abortions? If you think they should not be jailed in cases of infanticide (perhaps because these situations often arise out of desperation), does that undermine your belief that infants are human beings entitled to equal rights?

Neither alternative is easy or comfortable to maintain. All of us are probably somewhat uneasy about sending women to jail for killing their newborn infant. But all of us likewise maintain that to kill a newborn infant is murder. So there are no simple options for anyone – no one is off the hook. To illustrate this, recall that one of the UK Parliament’s most ardent pro-abortion MPs a few years ago explicitly included in her abortion decriminalisation Bill a provision to prohibit abortion after 24 weeks, including life imprisonment for those who violated it. She had to include this provision to show the overwhelmingly pro-choice population that she was not an extremist who supported abortion up to birth – but that prohibition naturally came with a severe penalty for breaking the law. No one – not even Parliament’s fiercest pro-abortion advocates – finds this an easy balance. In theory, could it be just to imprison someone for an abortion? I think all of us would have to say yes: surely someone who performed a partial birth abortion on themselves for a trivial reason (suppose they discovered the sex of the baby at that moment) has done something seriously wrong and is deserving of punishment. So the fact that this question is difficult for pro-lifers shows little in itself: it is a difficult question for everyone.

Of course, abortions that late for such trivial reasons are very rare, which is precisely part of the reason a pro-lifer can reasonably say that, in practice, women should not be punished for abortion.

Bear in mind at the same time that abortion advocates portraying pro-lifers as evil for (ostensibly) wanting women jailed is somewhat disingenuous: there are plenty of proposals across the world to ban pro-lifers from, for example, offering support to women outside abortion clinics – and these are very often women themselves. Laws banning such behaviour usually include a provision for imprisonment if a woman violates such a law by offering support (or – thought crime being a real thing – in some cases even silently praying outside a clinic). Likewise, some jurisdictions have put forward proposals to jail doctors who refuse to perform abortions against their conscience (in Kenya, they proposed a 3 year jail term along with a million shilling fine). In Argentina, Dr Leandro Rodriguez Lastra was given a suspended 14 month jail term for not performing an abortion against his conscience (and his clinical judgment).

You might disagree with the actions of women offering support outside abortion clinics, or silently praying, or doctors (male or female) who refuse to perform abortions. But you probably also think that putting them behind bars is hideously draconian. What this shows is that anyone from both sides can be criticised for ostensibly wanting to see people locked up – the difference is that pro-lifers clearly do not support women being jailed for abortion, whereas abortion advocates clearly do want to see pro-lifers put in jail for these various activities.

But why do pro-lifers not support putting women in jail for abortion, if they really think it is so serious?

There are a variety of reasons – other than opposing retributive punishment in general – why you might think that individual women should not go to jail: many abortions are coerced; many men abandon their partner and children putting women in this position while escaping without responsibility or punishment; many women do not know, or are even lied to, about the reality of unborn life and hence are usually unaware that the unborn child is a person; many abortions are done out of desperation, and so on.

Another reason for opposing jail is that you might think it is not the best way to humanise unborn children in the long-term. My own instinct is that it would be far more effective, life-giving and merciful for women having abortions to be counselled about foetal development and why abortion is harmful to both mother and child, and then given the practical support she needs to avoid abortion in future.

Yet another reason, and an historically important one, is that women are less likely to report the person supplying abortion pills or performing the abortion if they are at risk of prosecution as well.

Given the state of our culture on the question of abortion generally, the inequalities between men and women when it comes to abandoning children, the difficulty in determining whether someone really believed their foetus was a person or not, and so on, it seems reasonable as a practical matter for these individual exemptions to be generalised. There may be some cases where the evidence of serious wrongdoing is so clear that jail is seemingly appropriate and could override the presumption of non-culpability – but that is true for everyone, whether they are pro-life or not – for example, a partial birth abortion because the baby is a baby girl. So no one is immune to this possibility.

In short, there are good reasons to support a presumption of non-culpability for women obtaining abortions. In the rare cases where there is clear evidence of culpability and serious wrongdoing, there are two options: continue to apply the presumption of non-culpability anyway as the best practical option, or apply punishment in these rare cases. Opinion among pro-lifers might be divided on that question. But here’s the key point: opinion among pro-choicers would be similarly divided on that question. It is not a problem unique to the pro-life view: it is a problem arising from the conflict between moral commitments that all of us share with our instinctive sympathy for new mothers.

In sum, there are no easy answers for anyone – pro-life or pro-choice. No one wants to see women jailed, but we all want to see human beings protected – it is just a question of to whom we extend that protection. In practice, for the reasons I gave, there are good reasons to presume that women having abortions are not culpable as the default position. Whether that presumption should ever be overturned for the purposes of retributive punishment is a difficult question for both pro-lifers and pro-choicers.

Should women having miscarriages be investigated for murder?

If miscarriage involves the death of a human being, and indeed a very premature death, doesn’t it follow that women who have miscarriages should be investigated for murder?

This question encompasses two questions: should women be investigated for murder in these situations, and are they investigated for (and even charged with) murder in countries where abortion is illegal? We’ll begin with the first question.

In general, deaths are not investigated for murder, for two general reasons: a) in most cases it would be a complete waste of time, and b) it would be unnecessarily distressing to those most deeply affected by the individual’s death.

These factors are, of course, maintained in the case of abortion. There are many thousands of miscarriages a year in the UK and many millions in other countries. It is thought that around a quarter of all known pregnancies end in miscarriage, and an even higher number of spontaneous abortions occur before the pregnancy is known about. To investigate all of these would be a complete waste of police time, and be unnecessarily distressing to the mother and others, who are grieving their lost child.

For these reasons, we generally set a threshold of suspicion for investigating deaths – there has to be substantial specific evidence that the death was procured by another person. Of course, most of us already agree that in some cases abortion has to be investigated by police – if there is suspicion of a coerced abortion, for example, or if there is suspicion of partial birth abortion in the third trimester. So the fact that this threshold is sometimes crossed is not a problem for the pro-life position.

But in general, that threshold is not crossed. In most cases, it would be a waste of time and be profoundly distressing to the mother and others.

Another factor is that, as I have argued in another article, women should in general not be retributively punished for having an abortion. Hence the likelihood of conviction is even lower, which is another reason not to routinely investigate miscarriages.

Hence there are good reasons to set the bar high for investigating the death of an unborn child. This bar can be met – as we all agree – but usually is not.

Is it, in fact, the case that women are investigated for miscarriages and even punished for them?

In the overwhelming majority of countries which prohibit abortion (and in countries which make it illegal after a certain point, or without following certain procedures), there is not even the claim that this happens. In the UK, an abortion without two signatures from doctors is illegal (except in an emergency), and yet no one is ever investigated for a miscarriage. Likewise in pro-life countries like Malta or Poland, this is never suggested.

There are a few countries where it is claimed that women are investigated and punished for having miscarriages. In my view, the evidence for this is extremely thin.

Regardless, even if it is true that this has occasionally happened, it certainly is not a common occurrence even in those countries. Thousands of miscarriages occur in El Salvador every year, for example, and very few are investigated by the police. Outside these countries, investigation of miscarriage is overwhelmingly rare globally. And it certainly does not need to be a part of pro-life legislation.

Is it reasonable to vote based on abortion alone?

It is sometimes suggested that to vote for a political candidate only on the basis of their stance on abortion is misguided. I give an argument for single-issue voting on abortion in my paper on this topic, available with my other academic papers here: https://calumsblog.com/academic-papers/

Is the pro-life view speciesist?

Why is being human morally relevant?

Is personhood based on viability?

Is personhood based on sentience or consciousness?

Is personhood based on birth?

Is infanticide permissible?

How can killing an early embryo be seriously wrong?

Would you save a 5 year old or a frozen embryo?

Why prioritise abortion over miscarriage?

“Most embryos are miscarried”

“Skin cells are human life”

“Potential is morally irrelevant”

“Acorns are not oak trees, and embryos are not humans”

“Sperm have the potential to become a human”

Are all abortions equally wrong?

Other ethical and metaphysical questions

Is the pro-life view speciesist?

There are a variety of pro-life views: pro-lifers do not all agree on why they are pro-life, and they disagree on a few marginal cases. But it is probably fair to say that most pro-lifers think that being human is morally relevant, even such that a human being with minimal cognitive abilities has more value than an animal with more cognitive abilities. It has been alleged that this amounts to ‘speciesism’ – morally comparable to racism or sexism, in that it involves prejudice or discrimination based on an arbitrary, morally irrelevant characteristic. Sometimes it is claimed that this human exceptionalism has its roots in, and can only be justified by, certain religious views.

It is worth briefly mentioning that some of the temptation towards the ‘speciesism’ allegation is because of the way in which human exceptionalism has been used to mistreat animals, in many cases with great cruelty. It should therefore be noted that human exceptionalism does not imply that animals may be mistreated, so this should not be used as a mark against the theory, even if it means that many proponents of human exceptionalism historically have been morally flawed. Of course, it may be that human exceptionalism is false and all animals have a right to life – but if so, then it seems most plausible that human foetuses also have a right to life.

It will help to be clear about what, exactly, speciesism is. Jeroen Hopster has a helpful explanation of what speciesism actually is here. He points out that human exceptionalists are not necessarily speciesist: you might think that humans, in general, are more morally valuable than animals, but that when their interests are alike (e.g. in avoiding the same sort of pain), they should be treated equally. Since pro-lifers could take this view, they are not necessarily speciesist. So there are two options for the pro-lifer: defend speciesism, or reject speciesism while still defending human exceptionalism. The latter is perfectly possible and is the approach I endorse.

Although human exceptionalism is often claimed to have its roots in religion, it is defended by religious and non-religious philosophers alike, who have both rejected the claim that this is speciesist. Shelly Kagan, for example, points out that as an empirical matter, people typically accused of speciesism don’t make judgments that are best explained by an arbitrary preference for our species. For example, neither Superman nor ET are humans (examples can be multiplied endlessly: Legolas, Gandalf, Buzz Lightyear…), but virtually every alleged ‘speciesist’ in the world would treat them in a similar manner to humans – and would probably treat their infants the same way. Hence it is unlikely that our moral assessment of humans value is based on a sheer prejudice for our species. There is probably some underlying factor explaining our treatment of humans and human-like species – even if we are unable to articulate or even identify what, exactly, that factor is.

Everyone will have some basic foundational moral convictions which they will use to determine which individuals are persons and which are not. Many use a cognitive criterion – you are a person if you have sufficient cognitive ability. But this could easily just be called ableist or cognitivist, akin to racism or sexism. Simply saying that it is an arbitrary prejudice isn’t enough: it needs to be demonstrated that it is an arbitrary prejudice. It is not clear from the evidence that those accusing pro-lifers of speciesism have shown this.

Coming back to our central question, however, it would help if we could identify and articulate what is it that makes humans exceptional, even in instances where their cognitive abilities are inferior to those of animals (as in the case of infants and some disabled people). Hence the next question.

Why is being human morally relevant?

We’ve established that believing in human exceptionalism isn’t necessarily speciesist. Speciesism is an arbitrary prejudice for a species (including a prejudice based on a morally irrelevant factor). If there is a plausibly morally relevant attribute which humans have, then this could explain human exceptionalism.

It’s worth mentioning that most people are committed to there being some criterion like this. After all, virtually everyone believes that humans with very severe cognitive disabilities, and indeed infants, have more rights than animals, even when those animals have more advanced cognitive capacities. Even if we cannot come up with an underlying criterion explaining why humans have more rights than animals (independently of their individual capacities), our intuitions about human equality must be given some weight. Ultimately there has to be some brute fact about where rights come from: maybe given our intuitions, ‘being a human being’ will suffice. Of course, much of our moral progress has been predicated on human equality as a brute fact – it has proven an intuitive and fruitful theory even in the absence of a unified underlying explanation.

But many ethicists have offered suggestions for why human beings are inherently valuable, and why it is that even very cognitively immature human beings should be considered as persons.

To fit with our basic intuitions, such a criterion should fit at least two criteria: disabled humans and infants should be included; and other beings intuitively counting as persons should be included. Some might also say that it should have some connection to paradigmatically human features: the capacity for rationality or advanced relationships of some kind, for example. Hence you will find that many of the theories – if not all – try to make a connection between this kind of attribute and individual humans who may lack that attribute (e.g. infants).

While human exceptionalism has often been seen as a theological or mystical doctrine, which some secular philosophers have disavowed precisely because of its theological basis, there are a number of secular philosophers – and even more secular theories – explaining the basis of human exceptionalism. Maybe humans are exceptional because they are made in the Image of God – and this should not be dismissed immediately, given how many people are theists and how morally fruitful this doctrine has been by comparison to virtually every other culture’s conception of human value throughout history. But we can also offer other suggestions.

For example, S Matthew Liao of NYU argues that having the genetic basis for moral agency suffices to make one a person. This would include human beings with severe disabilities and infants. And it could be tweaked – perhaps a ‘physical basis for the development of moral agency’ – to allow for aliens to be persons, if they were relevantly like us. David Hershenov suggests something along similar lines: roughly, you are a person if it is part of your healthy development to have the sort of cognitive capacities a typical adult human has. Shelley Kagan of Yale University proposes ‘modal personism’: you have the relevant moral status if you could have been a person. Jeff McMahan of the University of Oxford describes a variety of views, including that of TM Scanlon, known as ‘species norm’ accounts: these say something like, you are a person if you are a member of a species for whom it is normal to develop the kind of capacities adult human beings ordinarily have. For example, it is normal for a human to learn to talk, reflect deeply about the world, and so on. It would not be normal for a dog to do so. Another way of putting it: we consider humans unfortunate if they are not able to do these things. But we do not consider dogs unfortunate when they are not able to do these things: that is just normal for a dog. For these reasons, we might spend significant resources on helping a human to talk, thinking that they are deprived of such an ability and deserving of the opportunity to develop it. But we would not think anything like the same for a dog. This suggests that all of us do, in fact, consider humans and dogs to have different norms even if they happened to have the same abilities on an individual level. It is, arguably, these norms which determine moral status – and the fact that morality is, in general, about norms, makes this a fairly natural connection.

I think it is ideas like this which have led people for many centuries to call humans ‘rational beings’ – meaning that humans have as part of their inherent nature the ability to be rational. That does not meant every human being has rationality: they may be deprived of it by pathology, immaturity, or otherwise. But they are still the kind of thing which, in ordinary circumstances, would be rational (or self-aware, or capable of profound relationships, or morally responsible, or whatever one takes to be distinctive of humans).

It is worth noting that these sorts of accounts only need to give a sufficient condition for personhood. It might be that other individuals could be persons without fitting any of these criteria. So these accounts are not committed to saying that, for example, a dog who learned to talk and philosophise is not a person. Thus one of the main objections to these views (that they would not include such dogs) is unconvincing.

Hence there are a variety of plausible secular accounts of human exceptionalism. You need not be a speciesist to be a human exceptionalist. Nor do you need to believe in certain theological ideas. Nor do you need to take humanity’s moral value as a brute fact.

Is personhood based on viability?

Occasionally it is thought that viability is what determines personhood. This is perhaps more common in the UK and US, where viability has marked the legal limit for abortion on demand (in effect – though in the US post-viability abortions are allowed for almost any reason in practice as well). In most of Europe, there is a limit of around 12 weeks, and there is probably less emphasis on viability.

It is widely agreed among ethicists that viability does not change the inherent moral status of the foetus. It is hard to see how it could: normally our moral value does not depend on our ability to live independently of another person; this would seemingly suggest that anyone who was in any way dependent on others – whether people in hospital or on welfare – is not a person. Indeed, many people have pointed out that newborn babies are hardly able to live independently without significant effort from others.

You might think that viability is important because after viability, a wider group of people can sustain the baby and the baby is no longer dependent on her mother alone. But this doesn’t affect the inherent value of the baby – it is more of a claim about the duties the mother has towards her child.

Pro-choice philosophers have pointed out various problems with the viability position. Michael Tooley, for example, notes:

“The fact that an organism … is capable of physiological independence, is surely irrelevant to whether the organism has a right to life… consider a speculative case where a fetus is able to learn a language while in the womb. One would surely not say that the fetus had no right to life until it emerged from the womb, or until it was capable of existing outside the womb. A less speculative example is the case of Siamese twins who have learned to speak. One doesn’t want to say that since one of the twins would die were the two to be separated, it therefore has no right to life.”

Likewise, Peter Singer writes:

“The point at which the fetus can survive outside the mother’s body varies according to the state of medical technology… do we say that a six-month-old fetus should not be aborted now, but could have been aborted without wrongdoing thirty years ago?… Suppose that for some reason a woman, six months pregnant, was to fly from New York to a New Guinea village and that, once she had arrived in the village, there was no way she could return quickly to a city with modem medical facilities. Are we to say that it would have been wrong for her to have an abortion before she left New York, but now that she is in the village she may go ahead? The trip does not change the nature of the fetus, so why should it remove its claim to life?”

Again, while it might seem plausible that viability changes the mother’s obligations towards the child, it is not at all plausible that viability changes the child’s inherent value, for reasons like these.

The viability suggestion is likewise highly vulnerable to improved medical technology. Viability has reduced dramatically in recent decades, with the youngest baby now born at 21 weeks and 1 day. Artificial wombs are rapidly improving (see video here), with mice able to be gestated artificially for the entire first half of pregnancy, and humans already able to be gestated artificially for pretty much the entire second half. It is conceivable that in the next few decades, artificial wombs will allow babies to be gestated for the entire pregnancy, which would, on the viability view, make embryos persons from the beginning.

Is personhood based on sentience or consciousness?

An intuitive suggestion is that personhood is based on sentience or consciousness – the capacity to feel or experience certain things. Some of the definitions here are fairly vague, but these views can broadly be separated into two categories: simple sentience, and complex consciousness.

If personhood is based on simple sentience, then presumably any animal which is sentient (which most people believe to be most of them, at least most vertebrates) counts as a person. This seems very counter-intuitive: while some (though clearly not most) might think that every sentient animal has a right to life, and might consistently live this out through vegetarianism (and being pro-life!), it is highly counter-intuitive to think that they not only have a right to life but are equal persons. This would require treating mice, for example, as having the same value and rights as an adult human being. I have never met anyone who believes this.

It would, of course, also require attributing personhood to the embryo or foetus at a fairly early stage (see ‘Embryology and the beginning of life’). Since we can never know for certain whether the embryo is conscious, a cautious approach might require us to attribute personhood at a very, very early stage of pregnancy (there are active neurons within a few weeks of fertilisation). As suggested in ‘When does consciousness begin?’, there is no longer any reason to doubt that foetuses are sentient at 10 weeks after fertilisation, and perhaps before.

If personhood is based on complex consciousness, then a threshold will need to be defined. Again, there is evidence that foetuses have considerable conscious abilities late in pregnancy, but clearly not enough to be comparable to an adult human being. But the same, of course, is true of a newborn baby. This is why most philosophers – for example, Singer, Tooley, McMahan, Giubilini, and Minerva – have suggested that if personhood is based on these qualities, then both abortion and infanticide are permissible. This is extremely counter-intuitive (see ‘Is infanticide permissible?’).

There is another problem, however. If our moral value is based on complex cognitive abilities, then it is hard to see why people with even more advanced cognitive abilities are not even more morally valuable. To suggest that at a certain threshold moral value is suddenly equalised and cognitive abilities make no difference appears profoundly ad hoc and implausible. Hence, this view also threatens our commitment to basic human equality.

Is personhood based on birth?

Again, it is widely (if not universally) agreed by pro-life and pro-choice ethicists alike that birth makes minimal or no difference to the inherent moral value of the foetus/baby. It might be that birth makes a difference to the duties the mother has towards the child – but it does not change the inherent moral status of the child herself. After all, little of moral significance happens at birth. The main physiological difference is that the child begins to breathe air through the lungs rather than receiving oxygen through the umbilical cord – though of course some children (like myself) were not breathing to begin with at birth either!

I once assisted with a caesarean section for twin babies. At one point, I had pulled one baby out (yes, it was surreal) while the other was still in the womb, though not for very long. On what grounds could we have said that the baby ‘outside’ was a person while his twin brother was not? They had exactly the same level of development. To say that birth (by caesarean or otherwise) made a difference to their inherent moral value is absurd. It is impossible to believe that a mere change in location and the commencement of breathing is what makes someone a person.

Is infanticide permissible?

As discussed above, there is widespread agreement in academic ethics among defenders and opponents of abortion that the inherent moral status of the foetus does not change at birth. Indeed, the foremost defences of abortion depend on attributing a lower moral status to the foetus, and the standard ways of doing this also have implications for newborn infants. If being a person depends on some particularly sophisticated cognitive ability, then it is likely that infants are not people. This argument is broadly accepted by Peter Singer, Michael Tooley, Jeff McMahan, and others. Although it has been persuasively argued by Richard Hain in his doctoral thesis on infanticide that infants have considerably more advanced cognition than Singer suggests (and probably later term foetuses as well), still, infants are clearly very dissimilar to adult humans in terms of cognitive ability, and probably less sophisticated than some animals. If what makes humans distinct (such that they can be called ‘persons’, while animals cannot) is some cognitive trait, then infants probably do not have it.

It is for this reason that Singer and others have argued that infanticide is permissible for the same reasons that abortion is. In general, a pro-life view can be argued by pointing out that abortion and infanticide are morally similar (assuming bodily autonomy arguments do not work – for which, see ‘The ethics of choice’), and that infanticide is clearly wrong. Hence, abortion is likewise wrong. But what if someone accepts that infanticide is permissible, as some ethicists are increasingly likely to do?

When our intuitions differ so much that infanticide could be accepted by one person and thought to be murder by another, it is tempting to think that we are approaching ethical territory where we simply cannot resolve disagreements due to fundamentally different intuitions or worldviews. But in this case we need not give up so easily, for there are other wrongs done to infants on which we all still agree, which are best explained by infants being persons worthy of respect and basic rights.

Forgive me for the extremely dystopian discussion, but consider the following examples:

1. Farming: human babies are grown on farms and preventing from developing, so that they can be harvested for organs for use in transplants.
2. Experimentation: human babies are used for invasive medical experimentation under appropriate amounts of painkiller.
3. Sexual gratification: human babies are used for sexual gratification.
4. Discrimination: human babies are discriminated against on grounds of race or sex.
5. Mutilation: human babies are mutilated under analgesia for fun.
6. Clothing: human babies are killed with their skin used for clothing.
7. Food: human babies are killed for food.
8. Decoration: human babies are killed to be used as decoration.

All of these strike most people as horrific, some of the worst crimes imaginable – and I am sorry to even describe them.

But on the most sophisticated account given of why abortion and infanticide are permissible, it is not clear that they are necessarily wrong, as long as other people gain sufficient enjoyment from them in sufficient numbers. Jeff McMahan suggests there are two tiers of morality: with sufficient cognitive sophistication, individuals are ‘persons’ and subject to the morality of dignity or respect: to kill such an individual would disrespect them and so is inherently wrong (except in self-defence and other exceptional cases) regardless of consequences. Below that threshold of cognitive sophistication, individuals are not ‘persons’ and so still have interests, but these interests can be weighed against those of others and overridden as long as the interest of others are sufficiently strong. Thus, below the threshold of ‘respect’, individuals can basically be treated in a consequentialist way: they can presumably therefore be treated in any way so long as it brings sufficient benefit to others.*

If this is the case, then there is no principled obstacle to any of the above scenarios, so long as sufficient benefits accrue to others. Presumably even doing them without painkiller could be permissible, though would need a weightier justification still. It cannot be objected that these actions would give them worse lives when they grow up, because for some actions the child is killed as part of it, and for other actions the child could be killed (since infanticide is permissible) once the action is complete (see also the argument from prenatal harm under ‘Are there other arguments for the pro-life position?’).

Most people who endorse infanticide would not endorse performing any of these actions on a newborn infant. But that cannot be because they are persons (since that is what they are rejecting), it cannot be because of the physical or mental pain experienced by the infant (since in most cases there is no pain, and such pain could be outweighed by the interests of others), and it cannot be because it would make the infant’s life worse when they grow up (since they need not grow up). Hence, there is considerable difficulty in explaining not only why these actions are wrong, but why they are so heinous.

The pro-lifer can easily explain why these actions are wrong: human infants are persons, just as human adults are. They therefore have a right to life, and a right not to be dehumanised, degraded or otherwise disrespected in these ways.

Again, this is only a brief sketch of a relatively dystopian area, so please forgive my brevity. The argument is given in considerably more detail in my published paper with Daniel Rodger and Bruce Blackshaw, ‘Beyond Infanticide’, published in The New Bioethics and available with all my other papers here: https://calumsblog.com/academic-papers/. I have a second paper in progress on the same general theme, available on request.

* More specifically, McMahan says that individuals have time-relative interests, not just interests. The rough idea here is that individuals have an interest in various things in the future, including living. But those future interests are less weighty – less important – if the psychological connections between the individual now and the same individual at that time in the future are weaker. For example, I have an interest in still being alive tomorrow. But if the psychological connections between me today and me tomorrow are weak – perhaps I barely remember where or who I am from one minute to the next, and cannot form any new memories – then my time-relative interest in still being alive tomorrow is considerably weaker and can more easily be outweighed by something else.

How can killing an early embryo be seriously wrong?

This is perhaps the biggest obstacle to the pro-life view for many people, along with concerns about bodily autonomy. It is perhaps bigger than the concern about bodily autonomy, given that the overwhelming majority of pro-choice people do support banning late abortion.

There are some obviously bad ways of stating this objection, such as the common claim that the early embryo is a ‘clump of cells’. It is true that the early embryo is a clump of cells, but it is also true that Roger Federer is (for the most part) a clump of cells, and yet he is a much-loved member of the human family whom most people (even his fiercest rivals) consider to be a person with inalienable rights. Sometimes, when he is fast asleep and not dreaming, he is even an insentient clump of cells. Yet despite such a dehumanising description, his moral worth remains intact. There is a strange denigration of biology here: we are biological beings. Biological material – however mundane it might seem in some ways – can be profoundly valuable.

Still, the basic hesitation is a fair one. It is unintuitive to many people that early embryos are persons, and this is an intuition with which I can sympathise. So I will spend considerable time responding to it – please bear with me! There are six basic points I want to make:

1. Every view has some counterintuitive implications: these are unavoidable but should be minimised
2. Our superficial intuitions are not reliable on this question and related questions
3. Consciousness is important, but not necessarily current consciousness
4. The badness of death is perplexing either way
5. There can be seriously wrong actions which lead to no suffering
6. We should prioritise reason over intuition in this case

I conclude that the pro-life view is, all things considered, the most reasonable.

It is worth being clearer about exactly what we are talking about, since it is commonly thought that late abortions are exceedingly rare, and therefore that the overwhelming majority of abortions are performed on ‘clumps of cells’. As I described under ‘When does consciousness begin?’, we have no way of really knowing for sure when consciousness begins. But there is good reason to think it is significantly earlier than has previously been thought. It is now thought by the leading pro-choice foetal pain expert that pain may be experienced from as early as 10 weeks after fertilisation, and some have argued that it may be possible even earlier. In 2020, 24,777 abortions occurred after this point in the UK alone (a conservative estimate assuming gestation was measured accurately and abortion pills were taken the same day they were posted – neither of which are likely). It does not matter how many abortions occur before consciousness if these abortions are seriously problematic – they remain a serious moral problem in and of themselves.

As mentioned, it is possible consciousness begins even before this point – though it is pretty impossible to tell exactly when it would start. So we can only be really confident that embryos are not conscious for perhaps the first few weeks of pregnancy.

The phrase ‘clump of cells’ is obviously relatively uncharitable even for very early embryos – as if the embryo were just an amorphous pile of some material. By 16-21 days there is a functional heart, and by 4-5 weeks the baby is already moving spontaneously. Other landmarks are covered under ‘Embryology and the beginning of life’. Videos of the embryo at just 4 weeks show that it is anything but just a ‘clump of cells’. By 8 weeks it is plainly identifiable on video as something deserving at least some respect. At 6 weeks it is not too dissimilar.

The embryo is, of course, from the very beginning, highly complex and highly organised, to put it mildly. I suspect it would be difficult to find a biologist in the world who is not impressed – even in awe – at times, at the complexity and organisation involved in even the most basic biological features of the zygote, compared with inorganic material. There is clearly something different at fertilisation, something with the inherent recipe, blueprint and organisation to mature into an adult human being – all that is needed from this point onwards is time, nutrition and oxygen. From the very start, the embryo a) acts towards clear goals (getting to the uterus, developing structures for implantation, preserving its structural integrity against further sperm, beginning a body plan, and so on); b) has differentiated parts for specific functions, among the different cells; and c) co-ordinates those parts and their functions to attain those goals. There is evidence even by the two-cell stage that the cells have differential gene expression to perform different tasks. And so on. More of the details can be found in George and Tollefsen’s Embryo.

There is a reason science nerds love science, well exemplified in this video (biology starts around 4:50). It inspires awe – reverence, even, when genuinely studied.

Of course, this reverence is not enough to demonstrate that it is a person. Bacteria inspire the reverence of biologists as well, but are not persons. All I am saying at this point is that we should not conceive of the early embryo as simply a blob of matter. It is a profoundly intricate, complex, system with clear (unconscious) goals, co-ordination, and so on. Organic material – especially organisms – rightly inspire reverence and wonder.

In the case of human embryos, of course, this amazing organism is not just like any other amazing organism – a bacteria or worm – it is in an important sense one of us. It is a scientific fact that it is a human organism. And this very same thing – with just a bit of time and nutrition – will most likely be something very much like us. Moreover, it is one of our offspring. It has two mature human parents and is their kin. Think of it another way: you were once that thing. It is a pretty incredible journey to have come from that – but it really is your journey. If you think you are worthy of wonder (in the sense that every human is), keep going back in your timeline, long before you can remember. It might be easy for some to look at an unfamiliar embryo in a petridish without any sense of wonder. It is slightly harder to look backwards at yourself without at least a hint of awe.

Those are just some of the reasons to think that the human embryo is profound not only because it is a wondrously complex and co-ordinated, awe-inspiring biological organism. It is all this and it is one of us.

This might get you some way towards seeing how a human embryo – even a zygote – could be the object of such zealous protection. For some of you, the penny might be well and truly on the floor already. But for others, you may need more than this. Others might be plainly unconvinced. So let’s answer this question in more detail. How can it be seriously wrong to kill an early, presentient embryo?

1. Every view has some counterintuitive elements

The first thing to say is that the pro-life view is not the only one with some immediately counterintuitive implications. Every view has these. As I’ve discussed in various questions, there is pretty much a consensus within academic bioethics that if late-term foetuses are not persons, neither are infants, nor certain disabled people. Since they are not persons, it is plausibly permissible to kill them (or commit other would-be crimes against them – see ‘Is infanticide permissible?’) for sufficiently serious reasons. Thinking that embryos are persons may be counterintuitive, but it is safe to say that condemning infants and many disabled people to non-personhood and non-equality is a fairly big bullet to bite as well. There are of course other options: maybe you think personhood depends not on being as rational as a mature human, but on consciousness. But then probably all mammals and maybe even many insects are persons, and this seems yet more counterintuitive.

If what I’ve argued in this ethics section is correct, all the most plausible views other than the pro-life view at least commit you to these sorts of counterintuitive implications – a rejection of human equality even for neurotypical or cognitively mature adults, a rejection of personhood for infants and certain disabled people, and so on – or else a far too broad conception of personhood whereby other animals and even insects (and, of course, many foetuses from a relatively early stage) are persons, equal to the rest of us.

So it’s not as if you can simply avoid strongly counterintuitive positions just by not signing up to the pro-life ticket. Every option is riddled with deeply counterintuitive implications. If I had a choice between accepting embryos into the human family and excluding infants and many disabled people from it, I would readily choose the former. But this is only the first of many considerations. Let’s go further.

2. Our superficial intuitions are not reliable on these questions

To put it simply: if our intuition about early embryos is unreliable, then probably the central objection to the pro-life view collapses. There are a variety of reasons to think our intuitions are unreliable:

a. Most simply, our intuitions here are not particularly widely shared. As I explain in point 6, even I no longer have this intuition (though I used to). Moreover, it is fair to say that a huge number of people historically and in the 21^st century retain an intuition that killing an early embryo is wrong – and this is not because they have false empirical views about its consciousness. For example, it has been known for at least a couple of centuries that early embryos could not experience anything – and yet the overwhelming attitude among doctors in the UK throughout the 19^th century and the first half of the 20^th century was that abortion was a very serious wrong – recall that the World Medical Association until 1983 had wording committing all doctors to ‘maintain the utmost respect for human life from the time of conception’, while the British Medical Association (more progressive than most) in 1947 referred to abortion as ‘the greatest crime’ along with suicide and murder. These were long after the decline in devout religiosity in the West. See point 6 for more discussion of this point.

Another case of differing intuitions is when embryos are wanted – or when the embryo was us. In those cases, we usually do not find it at all strange for people to put great value in the embryo and see it as significant in itself – to see it as a burgeoning human being, rather than just a clump of cells. When parents see their baby on ultrasound for the first time, it may or may not be conscious – but that is irrelevant to the fact that they instinctively see it as a baby, and sonographers do not usually ‘correct’ them by pointing out that it is an insentient clump of cells.

Likewise, many people are prepared to recognise that the embryo is a ‘baby’ – something morally valuable and perhaps even sacred – when it first has a heartbeat (16-21 days after fertilisation). But of course, having a heartbeat in itself is not morally significant – and people usually know this on reflection. Yet it is a case of reasonably widespread (though of course not unanimous) acceptance that an insentient ‘clump of cells’ is something worthy of our respect.

b. Our intuitions in the Western world in general have been particularly shaped by an historically unusual picture of ethics, as Jonathan Haidt has described in his book The Righteous Mind. We have come to be anomalously influenced by a very narrow hedonistic view of ethics (mainly due to the influence of utilitarianism, even on people who are not utilitarians), in contrast to the overwhelming majority of human cultures, which had a much broader range of moral concepts. See point 5 for more discussion of this point.

c. Our intuitions are based to a large degree on the shape or the look of the embryo. This is (in my view) obviously morally irrelevant. But yet it is clearly part of our intuition that early embryos are not persons. After all, throughout history, an enormous number of people have cited the fact that the embryo does not look like a human, or a baby, to support the suggestion that it is not a human and therefore not a person. In the modern day, likewise, it is extremely common for people to instinctively say that it does not look human.

This makes sense from an evolutionary perspective: humans have evolved to be particularly drawn to faces, especially eyes, and of course to find particular things about babies cute. Most of these are not present in the very early embryo, though of course the eyes are visible a few weeks, and by that point people are more inclined to see this as a human being. But of course, this evolutionary preference for faces and eyes is not relevant morally – though it has had (and probably continues to have) a harmful effect on those whose faces have been disfigured by various causes.

Perhaps one way of seeing this is to imagine that, from the very start, the embryo looked like a human baby and perhaps was even the same size (somehow) – but was still unconscious. We would probably find it nowhere near as unintuitive to say that killing it was wrong. On reflection, we might wonder whether killing it was wrong, since it is not conscious yet, but we would not find the idea that killing it is wrong as crazy as we do with an actual embryo in the real world.

But yet the baby’s form obviously is irrelevant. If the two-cell embryo was fully conscious, able to reflect philosophically and experience pleasure, and so on, we would all consider it a person. So I suggest that the shape of the baby is responsible for a considerable part of our intuition on this question, and yet is clearly misleading.

d. Likewise, evolution has not led to us being able to see the early embryo, or to be able to do much about miscarriages. So it is again not too surprising that we would not necessarily have evolved a strong sense of concern for early embryos. In that sense it might be seen as something of an historical accident – in another universe in which we could see the embryo for the entirety of pregnancy, and were in a position to do things to protect it, it is perfectly plausible we would have had completely different intuitions. Hence our intuitions in this case might well be seen as somewhat accidental and not especially geared towards truth.

e. Our intuitions on who counts as a ‘full human being’ throughout history have very often been wrong. Many, probably most, cultures have thought it obvious that people of other races were less valuable because of how they looked. Many cultures have thought that women were obviously inferior to men: Plato wrote that “if a person lived a good life throughout the due course of his time, he would at the end return to his dwelling place in his companion star, to live a life of happiness that agreed with his character… But if he failed in this, he would be born a second time, now as a woman.” Aristotle concurred: “the male is by nature superior, and the female inferior”. Likewise, until the advent of Christianity (and tragically even in many ‘Christian’ cultures since), it was blindingly ‘obvious’ to most people that some people were naturally born to be slaves. See Aristotle again: “he who is by nature not his own but another’s man, is by nature a slave; and he may be said to be another’s man who, being a human being, is also a possession… But is there any one thus intended by nature to be a slave, and for whom such a condition is expedient and right, or rather is not all slavery a violation of nature? There is no difficulty in answering this question, on grounds both of reason and of fact. For that some should rule and others be ruled is a thing not only necessary, but expedient; from the hour of their birth, some are marked out for subjection, others for rule.”

In sum, there is no reason to think that our intuition in this particular case is particularly reliable, and several forceful reasons to give our intuition only very limited weight.

3. Consciousness is important, but not only directly

It is safe to say that the intuition is strongly rooted in the idea that consciousness is morally relevant – and without consciousness, it is hard to see how killing the embryo could be seriously wrong. I want to make three comments on this point (points 3-5 in this answer).

The first is that pro-lifers usually (though not always) agree that consciousness is important, and that our particularly advanced mental capacities are what make humans uniquely valuable. So it’s not as if pro-lifers have a crazy intuition that just being an organism makes you a person, or anything like that.

But pro-lifers say that ‘being conscious’ alone can’t quite be right. After all, there are many sleeping people, or comatose people, who are not conscious. So there has to be a basis for moral value which is somehow related to consciousness and which explains why sleeping and comatose people are still persons. An obvious example is: having the capacity for consciousness. But embryos have the capacity for consciousness: it is just a latent capacity which needs maturation.

At this point you might object and say that an immediate capacity for consciousness is needed. But why think that? There isn’t anything obviously morally relevant about having an immediate capacity for consciousness that is morally valuable, while having a latent capacity is not. Moreover, what counts as an immediate capacity for consciousness is unclear. Some people in particularly deep sleep may not have an immediate capacity for consciousness. Some people comatose because of a brain haemorrhage almost certainly do not. But they are still clearly persons. It is going to be difficult to define what is meant by an immediate capacity, and even more difficult to come up with a definition which includes all the adults we would want to include as persons. Suppose you are at the hospital, beside your partner is currently anaesthetised after surgery. You’re confident he or she is a person (naturally), because she has an immediate capacity for consciousness (whatever that means). But suppose the neurosurgeon enters the room and tells you that during the surgery, they had to temporarily remove part of her brain which is essential for consciousness, though they of course plan to replace it at a later time. There is no sense here in which your partner has the immediate capacity for consciousness. They do not even have the neural hardware to be conscious, as things stand. Still, you are convinced they are a person.*

What is it that persists throughout your sleep and comatose phases? You, the biological organism. So it is most plausible to suppose that that is what matters – a biological organism existing with a natural (if not immediate) capacity for consciousness.

The basic point is this: our intuition that consciousness is needed for personhood is plausibly misleading, because persons are normally conscious or soon will be. But deeper reflection on the relationship between consciousness and personhood shows that a capacity for consciousness is sufficient for personhood, and it does not matter how immediate or latent that capacity is, as long as it is there. Our intuitions are just not used to working in these unusual cases.

4. The badness of death is not based on conscious experience

Epicurus famously argued that death is nothing to fear, because if we are dead, we won’t know or experience it. This raises the question: why is death bad? And why is killing wrong?

Killing clearly can’t be wrong because it causes a bad experience. After all, you could kill someone quickly in their sleep, and they wouldn’t experience a thing. This tells us something extremely important: death has nothing to do with any negative things we might experience. So in this sense it seems early embryos are no different from adult humans. Neither of them experience anything in death. So clearly from this perspective, one need not be conscious to be harmed by death.

There is an obvious answer to why killing is wrong: because it deprives someone of experiencing certain goods in the future. But of course, if this is the reason killing is wrong, then abortion is wrong, since it deprives the embryo of experiencing certain goods in the future, as Don Marquis has famously argued. And further, it shows that it is possible to seriously harm someone without ever causing them any sort of distress. This will be important in the next section.

So to avoid this problem, you will need to say something like: killing is wrong because it ends consciousness. But it’s not clear why ending someone’s experiences is any worse than depriving them of experiences in the first place. It is wrong to end someone’s food supply. But it seems no less wrong to prevent them from ever having any food in the first place.**

There’s another theoretical puzzle about this problem. It appears to imply that having been conscious is more morally important than having a conscious future ahead of you. On reflection, this is profoundly counter-intuitive. It says that the possibility that you will experience conscious goods in the future is virtually irrelevant to whether it is wrong to kill you, but having been conscious (in the relevant way) – something which has already happened and is irrelevant to future consequences – makes you a person. This seems to have things backwards.

There’s yet another problem with this response: the Epicurean problem comes back to bite, since the person whose consciousness is ended never finds out that their consciousness is ended. They never experience the harm you’ve done to them. So there is another sense in which consciousness is not directly relevant to why killing is wrong. Neither the embryo nor an adult human being experiences the badness of death itself. Nor do they ever find out or experience in any way the fact that they have been deprived of future life.

This might all seem like a bit of a trick: but it is important. It demonstrates a critically important point: at the very least, it shows that death is not bad because it gives you any sort of negative conscious experience, whether the badness of death or remorse at being deprived of further life. So in this sense, at least, you do not need to be conscious to be seriously harmed by death.

(Here’s another example to see this point. Having sailed to a distant country to export some new medical imaging technology, you become shipwrecked on a desert island. You come across a pregnant woman on a desert island. She is fast asleep. Your friend decides to kill her painlessly for food. You, naturally, intervene: this is obviously a human person with a right to life. Your friend tells you she is unconscious, so it is fine to kill her. You respond that she will be conscious, so it’s still wrong. Your friend says that whether she will be conscious is irrelevant; what matters is whether she was conscious. You’re instinctively uneasy about this claim as you’re not sure that’s right, but you go along with him since you’re desperate for food and not wanting to get into philosophy. But there’s an obvious bigger problem: surely this pregnant woman was conscious, so your friend’s reasoning doesn’t apply. At this point your friend informs you that he has used that medical imaging equipment and has determined that although the organism was conscious in the past, her memory and everything about her specific personality has been wiped from her past life. She will be a new person with no connection to the old person. Hence, her former conscious life is irrelevant, even if it existed. This makes sense to you, so you both quietly kill her and make her into a substantial supply of burgers.

It seems clear that you have acted wrongly, and probably committed murder. But it cannot be because the woman is conscious, and it cannot be because she has recently been conscious – because she is completely disconnected from that former consciousness. So it is implausible to think that previous consciousness is as morally significant as it needs to be for this response to work).

Finally, it has been suggested that respect is the reason killing is wrong: Jeff McMahan suggests that this is the most promising way to explain why every person has an equal right to life, despite very different lengths and qualities of life remaining. That is to say, killing people is wrong because it violates duties of respect towards them – it disrespects them in a particularly heinous way. I am inclined to agree with McMahan on this, though we disagree on who counts as a person. But this account, of course, makes no reference to consciousness – only very indirectly (it factors into who is a person). In fact, the account introduces a fairly nebulous concept of ‘respect’ not directly related to consciousness. All sorts of unconscious things can be disrespected – dead bodies, for example. So this in fact offers another indicator of how it could be seriously wrong to kill an early embryo. None of us find it inconceivable how desecrating the dead could be seriously wrong, even though they are not conscious, and never even will be conscious again. By the same token, there should be no reason it is inconceivable that killing an unconscious early embryo who will be conscious could be seriously wrong. See the next section for more on this.

Of course, on this account the best way to know whether killing is wrong is to identify who is a person on other grounds: as I have suggested throughout, the only plausible accounts of personhood that explain our more fundamental intuitions are those which include embryos.

In summary, plausible accounts of the wrongness of killing generally do not require any sort of conscious experience of death, which is an indicator that consciousness may not be needed to be seriously harmed by killing. In fact, the more plausible accounts of the wrongness of killing clearly apply, or could easily apply, to embryos despite their lack of consciousness.

5. There can be seriously wrong actions which lead to no conscious suffering

Killing and desecration of the dead are examples of a wider class of actions which have no noticeable effect on the victim – meaning, the victim suffers no conscious negative consequences as a result. Sometimes these are called ‘harmless wrongs’, and they have been widely discussed in ethics. I want to also include actions which are harmful but have no conscious effect on the victim. Since we have a strong cognitive bias to connect harming someone and doing seriously wrong things with causing people to suffer, identifying examples where these come apart is helpful for comprehending how killing an early embryo could be seriously wrong. Here are a few examples:

• Your child dies. You and your family eat his corpse for dinner later that night.
• You are contacted by a former owner of your house, who say that they would like to bury their child in your garden, since it is where that child was born. They will never be able to visit, nor will anyone they know. Being a utilitarian, you realise it is obviously more moral to cook the child for dinner and donate the money you would have spent on food to purchase malaria nets for children in Sub-Saharan Africa. You do so.
• You deliberately use the pages of a famous anti-slavery speech as toilet paper. No one ever finds out.
• You are upset at a Muslim neighbour. Knowing he and many other Muslims would be greatly offended by it, you put a Qur’an on the floor and stamp on it until it is pulled apart. No one ever finds out.
• Your parent dies, and asks as their final wish that you visit their grave – just around the corner from your house – once a year. When the time comes, every year, you are enjoying playing a computer game, so you don’t bother.
• You see a severely disabled child build a sandcastle on a beach, and then you see him and his family finishing their holiday and going to their home far away. Knowing they will never see this sandcastle again, you kick it over for fun.
• You are a nurse in an operating theatre. When a patient is anaesthetised, you and the team mock a large birthmark that the patient has.
• You cheat on your wife. No one ever finds out.
• A famous civil rights activist passes away. No one is able to attend his funeral, and it cannot be streamed. Knowing that no one will ever know, you ask a local white supremacist to read the eulogy and perform the burial rites.

Jonathan Haidt gives a number of other examples: someone smears elephant dung on a picture of Nelson Mandela and displays it in their art museum; various cases to do with ‘harmless’ incest; the production of a sex robot deliberately created to look like a specific child (never seen again and incapable of being harmed) to be used for gratification; and so on. Consider also the cases I suggested in ‘Is infanticide permissible?’. The possible examples are endless.

If you are anything like the average person, you probably think that most of these are seriously wrong, even though they never harm anyone in a way that the victim could appreciate. The consciousness of the victim is completely irrelevant to the fact that they are seriously wrong. Indeed, in several cases the victim is already dead. But yet these things are seriously wrong.

It won’t be enough to say that they are seriously wrong because they could reinforce the bad attitudes of the culprit. Abortion could do that in various ways – it could desensitise people to the value of human life. And it is hard to believe that merely reinforcing a bad attitude that someone already has is in itself enough to make these acts so appalling. Likewise, it won’t work to say that they could offend people if people were to find out. Because in these cases, it is overwhelmingly likely no one will find out, and in any case the same could apply to abortion.

So the basic situation here is that we have a huge variety of things which are seriously wrong and yet which are completely irrelevant to the consciousness of the victim – because the victim never finds out, or is already dead, or is never cognisant of these acts or the harm they might cause.

Now imagine someone tells you they cannot even conceive of why these things would be wrong, because the victims are never conscious of the fact they have been wronged, and never suffer any noticeable harm from it. They insist that it’s just so counterintuitive to them that these could be seriously wrong. What would you say?

Every reader will probably have a different answer to this, so I can only speak in very general teams. It is very likely that the response you give to this person is the kind of response which could be given to someone who struggles to see how killing an early embryo could be morally wrong. Yes, it is true that the victims in all these cases are never consciously harmed, and never experience any negative effects. But all of these actions show egregious disrespect for a human being (in many cases a dead human being) and for certain abstract values or concepts. In the same way, although an early embryo will never be consciously harmed, and never experience any negative effects (though they will certainly be deprived of a future life, as with all killings), killing it shows egregious disrespect towards that young, immature human being, the value of human life, the value of human equality, and so on.

Of course, it is not just that the human being and the things it represents are disrespected; the infant is also deprived of life. We are often able to understand why depriving someone of the rest of their life harms them, even though they don’t notice the harm. The same is true in the case of early embryos. In fact, it is easier to see how killing an embryo is wrong than many of these cases. Why is it intuitive that someone who has completed their life, is dead and will never again experience anything can be disrespected, but that someone who has their whole life ahead of them cannot?

This is the kind of thing pro-lifers mean when they say that the early embryo is a person. They are not making the obviously false claims that it is conscious, has a personality, and so on. Perhaps this confusion is part of why it is so unintuitive to think that an early embryo is a person – it is clearly unintuitive (and indeed false) to suppose that the very early embryo is conscious (though it is quite possibly conscious before long – we simply do not know). When the claim is understood properly – the early embryo is a biological human being (which is scientifically uncontroversial), it is a member of the human family (albeit a very young and undeveloped one), it is the kind of thing all of us once were, and it is an entity with a future ahead of it and who will (likely) naturally develop into a conscious personality – I suggest that the claim is far less unintuitive than often thought, especially when all the above considerations are put together.

Jonathan Haidt’s work can also provide an explanation (perhaps a debunking one – see point 2) of just why so many in the modern West find this idea so unintuitive. Western societies, he claims, have a WEIRD morality (Western, Educated…). ‘Weird’ is not just a helpful acronym; it is also true. Western societies are historically extremely anomalous in the basic constituents of their moral thinking. Western societies typically have moral beliefs built on only two main pillars: care and fairness. By contrast, most societies throughout history have included other basic parts of morality: authority, loyalty, and in particular, sanctity/divinity. For various reasons, Westerners have largely dropped these latter three, especially the sanctity element. Part of the reason is, of course, secularism. Another part of the reason is that our moral thinking has been particularly influenced by utilitarianism which, Haidt notes, was conceived by an individual with autism with perhaps a different sense of interpersonal dynamics to most – this perhaps explains why so many of the above actions are so offensive to many people, but are not necessarily wrong according to utilitarianism. Utilitarianism cares only for pleasure or pain inflicted on other people (and oneself) by one’s actions: it attributes no inherent weight to loyalty, selflessness, respect, and so on (except insofar as they cause pleasure or pain).

It would be a mistake to think that sanctity is simply a religious concept, and since most people are not religious, they could easily discard it. For it does not refer only to supernatural dimensions of morality: it includes, for example, the reverence and respect we show to the dead – something very much a part of the morality of most non-religious people. In fact, there is a case to be made that all of the actions I listed above are violations of this kind of reverence or respect that we should have towards human beings and the ideals or groups they might represent.

So it is probably not true to say that Westerners have completely dismantled these elements of morality and rely only on care for others and fairness. In fact, they do retain a strong sense of sanctity, if only in certain situations less connected to supernatural phenomena.

These observations, I propose, explain much of why so many find it difficult to see how killing an early embryo could be seriously wrong. At the same time, the examples of disrespect I have suggested show that we can conceive of how harming something unconscious could be wrong. It can be wrong for exactly the same reasons that disrespect someone who never experiences any harm can be wrong (and also because it deprives the embryo of future goods).

6. We should prioritise reason over intuition in this case

For some people, this might have shifted their intuition itself. That has, in fact, been my change in perspective over the years – and it probably has been gradual. I originally shared the intuition that it was not wrong to kill an early embryo. But as I gradually reflected more and more over time on various things – the reasons killing is wrong, the grounds of moral status, the complex development of the early embryo, the nature of disrespect, and so on – my intuition itself began to shift, and I can now say I no longer even find it unintuitive that killing an early embryo could be seriously wrong, though of course I can still sympathise with those who do not share this intuition yet. I now have an intuitive sense of (at least) unease about taking the life of any human organism, no matter its shape or level of consciousness – even if that unease is not as strong as, say, my aversion to late-term abortion. This shift in intuition has not, I should add, led me to a particularly unusual place: in fact, I think it is likely that most of the world – or at least much of it – considers early abortion intuitively wrong, without relying on false empirical claims. As I mentioned in point 2, it has been known for at least a couple of centuries that early embryos could not experience anything – and yet the overwhelming attitude among doctors in the UK throughout the 19^th century and the first half of the 20^th century was that abortion was a very serious wrong – recall that the World Medical Association until 1983 had wording committing all doctors to ‘maintain the utmost respect for human life from the time of conception’, while the British Medical Association (more progressive than most) in 1947 referred to abortion as ‘the greatest crime’ along with suicide and murder. These were long after the decline in devout religiosity in the West. So maybe it is our intuition that has gone astray in this case (see point 2).

For others, your intuition may not have shifted at all, or shifted only a little. In that case, I propose this: given that every view has some counterintuitive implications, that is no reason in itself to fear the pro-life position. In that sense, there may be a level playing field – or maybe even tilted in favour of the pro-life position, given that the other positions have even more counterintuitive implications – the denial of human equality, the permissibility of infanticide, and more.

Moreover, given that our intuitions on embryonic moral status are not likely to be particularly reliable, and have certainly not been unanimously held across different cultures, we should not give them much weight, if any. Given also, then, that our intuitions can be easily explained with reference to moral psychology, and shown to be inconsistently applied (we believe in many harmless wrongs), given that the wrongness of killing is to some extent puzzling whichever view we take, and given that there are strong concrete reasons to think that killing an early embryo is wrong (as explained in the rest of this ethic ssection – it is the only way to uphold human equality, the wrongness of infanticide, and so on), I suggest that the reasons in favour of adopting the pro-life position far outweigh the intuition against it on this point.

Holding to a position even while considering it somewhat counterintuitive can certainly be done. That was my own position when I first became pro-life, though as I say my intuitions have gradually shifted since then. But we do this all the time in ethics. One of the most interesting – and frustrating – things about ethics is that virtually everyone arrives at views on reason which conflict with their basic intuitions. For example, Jeff McMahan himself says at various points that his own view in support of abortion has certain implications he finds very uneasy. But ethics is full of these conflicts. Moreover, virtually everyone studying ethics discovers that they have intuitions which are completely contradictory when the underlying principles are drawn out. Most of us consider it rational to change our positions, in conflict with some of our intuitions, in light of these contradictions, rather than holding onto them.

Hence I claim that the rational thing to do in this situation, if you still have not even hint of an intuition against killing early embryos, is to consider that intuition outweighed by the reasons discussed throughout this article and others. That may mean that for a time you have to believe something you find somewhat counterintuitive. That is fine – we have all seen optical illusions before! You will be OK.

*Or maybe you think they are not a person, but could still be a person, and that suffices to be treated as one. In which case, the pro-life position is proven by a different route.

**Of course, it can be worse in certain cases to end something someone already has, but that is usually because they are dependent on it or have gotten used to it, and will suffer more from being deprived of it than someone who never had it. But in the case of ending someone’s experiences, clearly they will not suffer more because they are ‘used to it’. They will not suffer at all, because they will be dead.

Would you save a 5 year old or a frozen embryo?

Suppose an IVF clinic is on fire and there is a frozen embryo – perhaps many – trapped inside. At the same time, there is a 5 year old child trapped inside. You only have time to save one. Which do you save?

This question has been thought to pose a problem for pro-lifers, because most people’s intuition is that you should save the 5 year old – not just over one frozen embryo, but even over many frozen embryos. It is suggested that this shows their lives cannot be equally valuable – especially if you should save one 5 year old over many frozen embryos. How can pro-lifers respond?

The first thing to say is that the intuition may not be as obvious as it first appears. Bioethicist S. Matthew Liao points out that you can modify the case so that the choice is between a 5 year old child, and a frozen embryo belonging to you and your spouse – your last possible embryo, in fact, since you have no children and your last egg has been used. At the very least, it is no longer obvious that you are obliged to save the 5 year old child. Liao points out that this is very difficult to explain if the embryo has no rights – after all, you wouldn’t be permitted to save your most prized possession – say, a unique Picasso painting – over a 5 year old child.

Regardless of whether Liao is right or not, the pro-lifer’s basic response is this: most people now agree that human beings are equally valuable and have equal fundamental rights. And yet most people also think that they can prioritise who should be saved in certain triage situations. Most people would, for example, say that a pregnant woman should be saved, other things being equal, over a non-pregnant woman. And these decisions aren’t only based on the number of lives saved: most people would save a now infertile 50 year old woman with 3 young children dependent on her over a still fertile 50 year old man with no dependents, while at the same time insisting that they are equally valuable and have the same fundamental rights.

Assuming the overwhelming majority of people are not completely irrational in this respect, it follows that human equality, and humans’ inviolable fundamental rights, are consistent with treating humans differently when it comes to saving people with limited resources, based on various different factors. These factors might include, for example, number of dependents, length of life left, likelihood of survival, integration into society, intimate relationships with others, being known to others (especially in intimate ways, e.g. family), pain and pleasure likely to be experienced in being saved, and so on.

Can these sorts of factors plausibly differentiate embryos from 5 year old children? It seems so. Frozen embryos are far less likely to survive, they have only marginally longer left to live (assuming they do), they are generally not integrated into society, they generally are not known to others, and so on. So these sorts of reasons could justify saving a 5 year old child over them. As Liao shows, when those factors are equalised – when the embryo is very much known to and valued by their family, for example – the intuition that one must save the 5 year old is far more tenuous.

Hence, in summary, two individuals having equal and fundamental human rights (such as the right to life) is compatible with prioritising them differently in emergency situations. Ideally, both would be saved – and it would certainly be wrong to kill either – but that is not always possible. Hence, the fact that we would save the 5 year old child does not demonstrate that the embryo is less valuable or that they may be killed.

That is the (relatively) short answer. For the long answer with a far more detailed theoretical framework, see my paper ‘The scourges’, published in the Journal of Medicine and Philosophy and available with my other academic papers here: https://calumsblog.com/academic-papers/

Why prioritise abortion over miscarriage?

A few philosophers – most notably Toby Ord, Amy Berg and William Simkulet – have argued that pro-lifers’ prioritisation of induced abortion over miscarriage, and/or their relative apathy towards miscarriage, imply that they do not really think that embryos/foetuses are persons with the same kind of value that you and I have. They point out that the number of miscarriages each year far exceeds any other cause of death, and far exceeds even the number of induced abortions. If all these tens of millions of babies lost to miscarriage each year are really persons, isn’t this a public health crisis of epic proportions, and a far bigger problem even than induced abortion?

There are a few things to say in response. First, the number of miscarriages is likely highly exaggerated. Second, a significant proportion may well involve a failure of any embryo to form at all – if so, then there is no organism which loses its life at all. Third, to characterise ‘miscarriage’ as a single cause of death is highly misleading. ‘Miscarriage’ just refers to the death of an embryo/foetus prior to 20-24 weeks (the exact cutoff differs according to various sources/countries; it is a ‘stillbirth’ after this point), not to a particular pathological process. To say that ‘miscarriage’ is a cause of death is like saying that teenage death is a cause of death. In fact, there are a wide variety of causes of miscarriage, and no one particular cause outnumbers deaths by induced abortion (which is a defined, particular cause of death).

Still, there are many tens of millions of genuine miscarriages each year; are pro-lifers inconsistent for not spending anywhere near the amount of resources on these combined as they do on abortion?

There are a few reasons for thinking not. First, many miscarriages may not be preventable without altering the identity of the embryo or foetus. The reason is that many miscarriages are due to serious genetic anomalies, and it may be that the genetic changes required to prevent miscarriage would be so substantive that the identity of the individual is changed – the first individual is extinguished and a new, genetically different individual takes its place. If so, then there is no imperative to ‘cure’ these individuals, because the cure is to stop them existing and replace them with a new individual – which is of course not a cure.

Second, enormous amounts of time and money are already spent on miscarriage research, far exceeding (probably even relative to the number of deaths) the time and money spent on anti-abortion activity.

Third, as I argue in my paper on this topic, there is generally a difference between killing and letting die, in part because killing necessarily disrespects the victim, whereas letting die does not necessarily. If the wrongness of killing is primarily grounded in the disrespect for human life shown by the culprit, and if abortion on a societal level involves significant dehumanisation and degradation of unborn children, these provide a significant motivation for preventing abortion which is not paralleled by miscarriage. Miscarriage does not typically involve disrespect for human life, dehumanisation, and so on. On the contrary, miscarriage is generally treated with considerable sensitivity and lament even by abortion providers and advocates. Hence there is a significant moral asymmetry which justifies anti-abortion activism more than anti-miscarriage advocacy.

Fourth, anti-abortion advocacy inherently doubles up as anti-miscarriage advocacy, because so much of it involves humanising the embryo/foetus and generating sympathy for it.

So there are a variety of reasons why anti-abortion advocacy might reasonably seem more urgent than anti-miscarriage advocacy, even despite the greater number of embryos/foetuses lost to the various causes of miscarriage than to abortion.

This is the very short answer to the question, which misses out a wide variety of important elements. For a full answer, see my paper, ‘The scourges: Why abortion is even more morally serious than miscarriage’, published in the Journal of Medicine and Philosophy, available with my other academic papers at https://calumsblog.com/academic-papers/

“Most embryos are miscarried”

It is true that many embryos are miscarried, and it is sometimes argued as a result that they cannot be persons.

But the standard estimates of miscarriage rates are probably unrealistic, as Gavin Jarvis at Cambridge has shown. Moreover, it is not clear what the argument is supposed to be. For much of human history, the infant mortality rate has been extremely high. But this obviously does not mean that they are not persons. This shows nothing at all about the value of embryos or infants.

For more on this question, see ‘Why prioritise abortion over miscarriage?’

“Skin cells are human life”

This is true, but it misunderstands what pro-lifers say when they say that ‘human life deserves protection’ or that ‘life begins at conception’. As explained elsewhere, pro-lifers know that skin cells are alive, and that they are human, but are not persons. When we say that life begins at conception, or similar things, what we mean is that an individual, living human organism is created at fertilisation – that is what we are, and so that is the relevant sense of ‘human life’. Maybe pro-lifers are a bit careless or vague when they make these claims: but when the claim is explained in full there is a clear distinction between a human organism and a skin cell. When we want to know what matters, we ask what we are. We are living human beings – that is, living human organisms – not merely ‘human life’ in a generic sense.

“Potential is morally irrelevant”

Some pro-choicers point out that we don’t normally treat potential Xs (in general) as Xs. We don’t treat trees as tables, for example, even though they are potential tables. So why should we treat potential human beings as if they were human beings?

It is doubtful whether the mainstream pro-life movement (academic or grassroots) has ever argued that embryos/foetuses are potential human beings and therefore have the rights associated with actual human beings. I have certainly never come across a pro-lifer who has made this argument, even though it is how the pro-life position is often presented.

Pro-lifers do not say that embryos and foetuses are potential human beings: we say that they are human beings, immature ones at the very earliest stage of their development – just as children are relatively immature and undeveloped, but still human beings. So pro-lifers do not rely on any sort of claim about potential Xs being Xs (or being entitled to the rights associated with Xs). Such a claim in general would be absurd.

Having said that, there is clearly at least one sense in which ‘potential’ is morally relevant. When you ask people why killing is wrong, one reason they often give is because it deprives someone of their future. But this is just another way of saying that you are depriving them of potential goods that they could experience. So in that sense most people are, in fact, in agreement that some kinds of potential can be morally relevant. And this kind of potential, as I pointed out in another question, is true of the embryo/foetus: killing it deprives it of the kind of future a human adult would normally experience – in fact, even more future. So it may be that there is a kind of potential which is morally relevant and true of the embryo/foetus.

“Acorns are not oak trees, and embryos are not humans”

‘Oak tree’ is the name for a grown member of a variety of species in the genus Quercus – that is, a member of that genus at a particular stage in its life-cycle. It is true that acorns are not oak trees: but they are both organisms of that genus, at different stages in their life-cycle.

Likewise, it is true that embryos are not human adults – but both are members of the species Homo sapiens at particular stages in its life-cycle. They are both the same kind of thing: a member of the same species.

The reason this is thought to be significant is that acorns are not valuable in the same way that oak trees are. But that is because the value of an oak tree is instrumental: we value oak trees because they are beautiful, or useful for timber, and so on. But that is not why we value human beings. We value adult human beings not because they are useful or beautiful, but because of what they are: human beings. But exactly the same is true of embryos: they are human beings in exactly the same sense. The only thing that this analogy tells us is that embryos are not adults: this is trivially true and completely morally irrelevant.

“Sperm have the potential to become a human”

As I argued above, it is doubtful whether pro-lifers have ever made the argument that embryos/foetuses are potential human beings and therefore should be treated like actual human beings. So to argue that something else is a ‘potential human being’ to show that the pro-life view has absurd implications makes little sense.

I  did point out, though, that there may be a kind of morally relevant potential that could make abortion wrong at least in most circumstances: embryos and foetuses usually have the potential to experience a meaningful future in the same way adults do. Is this true of sperm cells as well?

Unfortunately, sperm are not human beings. They have only half the genetic material required to develop, and by themselves, will not develop into a mature human being. When they enter an egg, they disintegrate. They could fertilise one of millions of different eggs, each forming a completely different person. In any case, it can’t be that the sperm and the egg are both identical to the zygote they form: if so, then by the laws of identity, they would be identical to each other (since if A = C and B = C, then A = B), and this is absurd.

What is going on here is that there are (at least) two different senses of ‘potential’ here: there is identity-preserving potential, and non-identity-preserving potential. What does this mean? It means that some things have the potential to become or experience something while remaining the same thing. For example, I have the potential to be a teacher or to learn Portuguese while remaining me: it would be me that was a teacher or knew Portuguese. By contrast, a tree has the potential to be a table or chair, but not while it retains its identity. It has the potential to give rise to a table or chair, but it is destroyed in the process. When it ‘becomes’ a table or chair, it ceases to exist.

Embryos have the identity-preserving potential to become an adult human being. That adult will be the same individual as the embryo, just much older and more developed. By contrast, sperm cells do not have identity-preserving potential to become an adult being, They have only the potential to give rise to an individual which will become an adult human being, but the sperm cell will not survive that process and remain the same individual. Hence the two cases are entirely different.

For more detail on some of the relevant metaphysics, see my paper on fertilisation with Alex Pruss at https://calumsblog.com/academic-papers/.

Are all abortions equally wrong?

This was a good question I was recently asked on a podcast. It is an interesting question because there are, I think, multiple ways of measuring the ‘wrongness’ of an action.

Pro-lifers generally say that unborn children are equal human beings, and hence have an equal right to life. Hence, the basic action of ending that life is inherently equally serious, and that life deserves equal protection against such killing.

But that doesn’t mean that every person who has, or performs, an abortion has done something equally wrong. There are many different cases of killing which are in some sense equally wrong, but with very different levels of culpability. For example, killing someone because you enjoy killing people of a certain race is very, very wrong. Killing someone because they punched you in the face is also wrong, though not quite as wrong. Killing someone in a perfectly sane state of mind is generally very wrong; killing someone because you suffer from barely controllable bouts of rage due to a mental disorder is still wrong, but the culpability may be somewhat reduced. And so on.

What these examples show is that culpability for killing can vary significantly – in some cases it might be entirely absent. But that is at the same time compatible with saying that the victims are all equally valuable and equally deserving of protection, and that in every case an infinitely serious right to life has been violated. So the short answer is: it depends. All abortions (except perhaps those justifiable to save the mother’s life) are equally wrong in that they all involve the unjustified taking of an infinitely valuable human life. But that is compatible with some of those abortions being very culpable, while others are barely culpable at all.

Other ethical and metaphysical questions

In time, I hope to answer a wide variety of questions on the ethics of abortion, going into considerably more detail and engaging with the most recent academic literature. I hope you’ll forgive me for not having had the time to do so yet (no one has paid me for any of the tens of thousands of words I’ve written so far!). But if you are the kind to be particularly interested in detailed questions in analytic philosophy (perhaps about animalism, or identity, or time-relative interests), then it is fair to at least tell you where you can find more detailed defences of the pro-life view. There are of course several academic books on the ethics of abortion – Frank Beckwith’s Defending Life and Christopher Kaczor’s The Ethics of Abortion (2^nd ed) are probably the two most commonly recommended. But even these do not go into some of the most detailed and recent debates relating to abortion. For those, my top recommendation would be the work of David Hershenov, who has a huge body of work on this topic (soon to become a book, I am told), covering all sorts of diverse ethical and metaphysical questions relating to abortion. All his articles are available here. S. Matthew Liao has a not so big but equally detailed and cutting edge discussion of a few of the relevant questions here. Stephen Napier’s edited volume has a variety of recent articles on the ethics of abortion. And, although I am biased since it contains two chapters of mine (on mental health and telemedicine abortion), a forthcoming Routledge volume edited by Nicholas Colgrove, Daniel Rodger and Bruce Blackshaw is likewise highly recommended.

What about women’s choice?

Judith Jarvis Thomson, the violinist argument, and bodily autonomy

“No one should be forced to be pregnant/give birth”

“No one should be forced to be a mother”

Is abortion self-defence?

What about women’s choice?

We arrive at perhaps the most common question people ask. Indeed, the whole debate is often summed up this way: pro-life vs pro-choice. At the same time, most people, deep down, dislike that terminology, accepting it only as a compromise to debate the subject without getting bogged down in debates about language. I hesitate to call it the ‘central’ question for reasons which I’ll explain shortly.

But first, I want to be cognisant of some of the reasons ‘choice’ is held to be so important. Far too often, historically and in the modern day, women have not been given choices to which they are entitled, and in particular, have had their bodies violated – whether through rape (including marital rape), abuse, trafficking, or otherwise. These are heinous crimes and are still not especially exceptional: almost all of us know a significant number of women who have been the victim of these abuses. I certainly do. And so I want to say, first, that I am grieved by this, and I am sorry for any way I might have contributed to a society in which this is so common, and where so few perpetrators are held accountable.

Our bodies are important; when they are abused, and especially in such intimate or invasive ways, it is horrific. It is, from this perspective, easy to see why we guard our bodily integrity so fiercely. It is especially easy to see why women are so determined to do so, against the backdrop of coercion and abuse – especially in cases where that has been personally experienced.

All that to say, I do not think we should approach questions about bodily autonomy and choice with any sort of triviality; for some people, especially, this a subject which revisits old scars and threatens to disrupt them again. I understand that, and so I want to say that I do not take the issue of bodily integrity lightly; I am aware of the gravity of the pro-life claim to many women, and want to humbly suggest that it is nevertheless worthy of being heard and accepted.

So why do I hesitate to call it the ‘central’ question? It is because I’m sincerely convinced – along with many pro-choicers themselves – that the moral status of the foetus cannot be circumvented, and that if the foetus really is ‘one of us’, then it cannot be justified (except where the life of the mother is at risk). In my experience, most people who use an argument based on choice in fact use two arguments together: when it is pointed out that we wouldn’t justify the choice to kill an adult in the same way, it is usually responded that this is completely different, because the foetus isn’t a person. But that just shows that the issue isn’t really about choice at all: it is about the status of the foetus. Most pro-lifers agree: if the foetus has no value at all, then of course abortion should be valid choice. What most of us disagree about is whether that ‘if’ is true.

This isn’t a niche pro-life view. Most of the leading defenders of abortion in the ethics and legal worlds agree entirely. Kate Greasley, for example, a pro-choice legal scholar at the University of Oxford, devotes half of her book to making this point: if the foetus is a person, then abortion cannot be permissible. Lord Mance of the UK Supreme Court, in his judgment supporting the imposition of abortion on Northern Ireland in certain circumstances, puts it this way: “if [the right to life] were held to apply to unborn life, no abortion could ever be legal. In the context of abortion the right enshrined in article 2 [the right to life] would be absolute”. Many more on the pro-choice side agree besides these.

So in that sense, this answer won’t make sense unless you’ve already understood (and hopefully accepted) my view on the equal dignity and value of all human beings, including the most immature and small. If you don’t even understand that view, then of course you will not understand this discussion about choice. You may want to consider reading those questions or getting in touch. Suppose you’re on board with that. Where to start?

Well, the first thing to say is that pro-lifers, of course, agree that humans should have choices in general, and that choices should only be restricted if there is a good reason. But they believe that everyone should have choices, and sometimes these choices conflict, and more fundamental rights or choices have to come first. This is not about saying one person is more important – the whole point of the pro-life view is that no one is more important than anyone else. It is about saying that there is a more fundamental right in the case of abortion – and it even makes sense to describe this as pro-choice.

A basic medical principle of medical ethics is that when someone is temporarily unable to make a choice – perhaps they are in a coma – we have to make choices in their best interests, as well as putting them in the right environment to be able to make choices again – by giving them treatment. We don’t simply say that because they are unconscious (perhaps for a very long time), they cannot make choices. Rather, we say that we will help them to become conscious again and make choices for themselves. We do this because a) they will be able to exercise choices in future, and b) they are still a human being.

Exactly the same applies to the unborn: they are temporarily unable to make a choice, and so we have to do what is in their best interests, as well as putting them in the right environment to be able to make choices in future: by giving them the nourishment and care that they need until they are older. They are still entitled to this because a) they will be able to exercise choices in future, and b) they are still human beings.

Second, no-one is fully pro-choice. Ultimately, everyone believes in some choices: we just believe that we should not be able to abuse our choices in order to seriously harm other people. That is why we have any laws at all – to prevent the abuse of choice and to protect the vulnerable. And this is why we have pro-life laws: not to stop people choosing in general, but to stop the abuse of choice and to protect the most vulnerable human beings. No one believes in unlimited choice.

If the debate were really so simple, then abortion should be available for any reason at all at any point in the pregnancy. But polling has always shown that even when people generally support abortion, almost everyone thinks there should be legal restrictions on abortion. For example, in the overwhelmingly pro-abortion UK, over 90% of women think that abortion on the basis of the baby’s sex should be illegal. Only half a percent of women think that abortion should be legal at any point in the pregnancy. It is obvious that supporting restrictions on abortion does not mean opposing women’s rights or women’s choices – otherwise, 99.5% of women even in the UK oppose women’s rights and women’s choice. This is implausible.

This is perhaps the best way to see that almost no one considers this a simple matter of ‘choice’. In recent years I have debated against two leading abortion advocates in the UK. One thought third trimester should be illegal; one thought it should be legal. But very few people considered the former ‘anti-choice’, even though she very clearly did not believe that women should have the choice to have an abortion in the third trimester. Why not? Because they recognised that once the foetus is a person, it has a right to at least some legal protection – even if that conflicts with somebody’s choice. In that sense, almost nobody is really pro-choice. They believe that the choice to have an abortion should be available until the foetus is a person. That is the same principle that pro-lifers adopt – so we are not, in fact, so far apart. (I say more about all this in ‘Why pro-life?’).

One way in which the ‘choice’ paradigm conflict with our intuitions is when it comes to babies who survived abortions – for example, Nik Hoot, who was aborted and lost both legs and has hand deformities, as a result. Nik is an inspiring young person making the most of his life, but who shows that abortion is not just a choice about a woman’s body: it is an attack on the body of another human being, which is usually fatal. More survivors can be found here.

Another reason the argument from choice struggles is because, paradoxically, legalising something does not necessarily make people freer. We already recognise this on topics like gay conversion therapy and hymen repair surgery. Different people will frame their opposition to these practices slightly differently, but self-identified liberals often want these things to be illegal for a reason like the following: although something being legal provides an illusion of freedom, in fact, in conjunction with economics and human nature, it can actually create space for coercion on a far larger scale. Choice is not always as simple as something being legal and available.

This would, of course, be recognised by the many women coerced into abortions, discussed under ‘How common is coercion?’. This coercion can come in the form of explicit pressure as well as implicit or soft pressures, as described there.

But going further beyond this, there is a somewhat sinister history of deliberate population control behind the major abortion organisations in international development. Both the founders of IPPF and MSI were radical eugenics advocates dedicated to population control globally, especially of populations considered by privileged Europeans and Americans to be unworthy. An early American Birth Control League (later to become Planned Parenthood) director, Lothrop Stoddard, wrote a book called ‘The Rising Tide of Color Against White World Supremacy’, and complained that ‘The black man is, indeed, sharply differentiated from the other branches of mankind…The negro… has contributed virtually nothing.’ Alan Guttmacher himself, after whom the Guttmacher Institute is named, was a devout eugenicist, who supported compulsory birth control if necessary: if population decline was not quick enough, he said, ‘we’ll have to get tough’, and ‘perhaps some day a way of enforcing compulsory birth control will be feasible.’

Marie Stopes herself was also a devout eugenicist who advocated for ‘half-castes’ to be sterilised at birth and lobbied for Bills to ‘ensure the sterility of the hopelessly rotten and racially diseased’.

For these reasons, most of the venerated founders of abortion organisations vehemently opposed charity. Lothrop Stoddard believed that social reform to reduce inequality was ‘one of the most pernicious delusions that has ever afflicted mankind’, and Sanger herself (the founder of IPPF) wrote:

‘Those vast, complex, interrelated organizations aiming to control and to diminish the spread of misery and destitution and all the menacing evils that spring out of this sinisterly fertile soil, are the surest sign that our civilization has bred, is breeding and perpetuating constantly increasing numbers of defectives, delinquents and dependents. My criticism, therefore, is not directed at the “failure” of philanthropy, but rather at its success.’

It is no surprise that memos were uncovered from IPPF archives showing their complicity in training abortion providers in China and claiming that the one-child policy was the ‘people’s own choice’. They were also extremely active in India during Indira Gandhi’s forced sterilisation campaign.

USAID report that African women generally want large numbers of children (as do others). Despite this, abortion providers and population control advocates insist that the ‘fertility rate’ of Africa must be reduced. It is also no surprise that the Guttmacher Institute – a Planned Parenthood offshoot – are still funded by multiple foundations with a history of mass funding for eugenics, including the Brush Foundation, whose founding ambition was ‘furtherance of research in the field of eugenics and in the regulation of the increase in population.’

The abortion movement has been closely linked from the start with the population control and eugenics movements. In addition to individual instances of coercion and soft pressure, there is a whole background of social engineering working against women’s choice, which is regularly neglected.

A final reason the choice rhetoric is problematic is because in order for choice to be meaningful, it has to be informed. And we know that abortion providers frequently do not provide women with the information necessary to give valid consent to abortion. For example, women are told that ‘abortion does not cause mental illness’. We know this is not true. We know that abortion providers often tell women that there is no baby, that it is not alive, that it cannot feel pain, and so on. We know that women are often not told about the available alternatives. We know that they are not told the truth about foetal development. And so on. Abortion providers vehemently oppose informed consent laws – laws requiring that abortion providers give the woman informed consent before making a choice. Abortion providers themselves have been condemned by hospital regulators for giving children and disabled women abortions without properly taking consent.

If a significant minority of abortions are outright coerced, and a large number more are done in response to soft pressure, and if a significant number of women do not have valid consent taken, we might wonder whether legalisation of abortion has, on balance, liberated women. The evidence I cite under ‘How abortion harms women’ suggests it has not.

But let’s come back to the central issue. Ultimately, all of us think some choices shouldn’t be allowed. Many who think that the choice to have an abortion should be allowed do not think that the choice to walk in crowded spaces unvaccinated without a mask should be allowed. Many oppose the choice to own a gun, carry a gun, say offensive things, discriminate against people, avoid taxes, and so on.

Some think that certain choices about one’s own body should be illegal: I have recently had conversations with fellow doctors about hymen repair surgery and gay conversion therapy. Most people strongly objected to their illegality, even with the consent of the ‘patient’. The reasons differed: no one could legitimately consent to these things; their existence risks serious harm to others who do not consent; and so on. But almost everyone agreed that even some choices about one’s own body should be prohibited.

Of course, for some of these there may be lives at stake. But for others there are not, at least not directly. No one is ‘pro-choice’ in general. All of us agree that choices can be limited where there is a risk of serious harm to others (and sometimes, if there is risk of serious harm to oneself). And so in the final analysis, the argument from choice doesn’t work when we ask: the choice to what? This isn’t just a choice about what to eat for dinner, or about body art. It is the choice to end the life of a human being. The debate about the value of the child cannot be escaped by appealing to ‘choice’.

Judith Jarvis Thomson, the violinist, and bodily autonomy

Nevertheless, there remain some people who argue that, even if the foetus is a person, abortion is permissible. This is not very common – but it has been famously argued in perhaps the most famous paper on abortion of all time: Judith Jarvis Thomson’s violinist experiment. In short, she says to imagine that you wake up one day, hooked up to a famous violinist. It turns out you were needed to save this violinist’s life, since only you have the right blood type. If you wait 9 months, he will survive. If you disconnect him, he will die.

Thomson argues that even though this violinist has a right to life, that does not entail that he has a right to use your body to sustain his life. This is an important point: Thomson is not simply arguing that it is morally OK to disconnect. She argues that it might still be callous, cruel, wrong, and so on. It just wouldn’t be unjust – it is not what the right to life entails. So as an argument for the moral permissibility of abortion, it is probably not sufficient even if it is correct: it might at best show that the baby has no right to your organs. It might still be wrong to disconnect from the baby. Arguably, at best it only justifies the legal permissibility of abortion, not its moral permissibility. Though it is unclear whether it would even do that.

It is worth saying at the outset that it is easy to see how some of the violinist argument can be intuitive when women are uniquely burdened by pregnancy, and when it has been so easy for men to abandon responsibility in the past. It is hard to blame people for thinking that if men bear no responsibility for their children, neither should women. That is only fair. But the solution, in my view, is not to say that neither have responsibility: it is to say that both have responsibility, and society should be much harder on deadbeat fathers. In fact, the legalisation of abortion has made such abandonment much easier and much more prevalent, as explained under ‘How abortion harms women’. There is of course no way for a woman to completely ‘share’ her pregnancy; but societies and, especially, fathers have a paramount duty to support them however possible.

Thomson’s argument is not widely accepted in academic ethics. As you might expect, in the 50 years since Thomson’s article, there have been a number of responses – even the leading pro-choice advocates – McMahan, Singer, Tooley, and others – have almost universally rejected it, for various reasons. Occasionally, it has been argued that it would, in fact, be wrong to unplug the violinist. David Hershenov argues this, and feminist philosopher Gina Schouten argues that specifically feminist ideals of care for the vulnerable and the mixing of the political and the personal suggest that vulnerable people like the violinist and foetus may indeed have a claim on our care. I highly recommend Schouten’s paper in particular (though Hershenov’s is also good). I also have a paper in progress on this topic, arguing that if we have an obligation to pay taxes (the fruit of our bodily labour), and if imprisoning us (an infringement on bodily autonomy) for not doing so is just, then even if abortion is merely letting die rather than killing, it could still reasonably be prohibited. Arguably, our attitudes to COVID say much the same: significant restrictions on bodily autonomy (lockdowns, vaccine mandates) are widely accepted for the sake of saving lives.

The argument has certain other limitations. Clearly it only works until viability: no one could possibly defend killing the violinist if it were possible to remove him safely with ease. This makes the argument particularly vulnerable to medical progress, and especially to artificial wombs, which are rapidly developing. That leading pro-choicers are worried about artificial wombs and think that decriminalisation of abortion is needed prior to that point suggests that they want to go far beyond what Thomson’s argument would allow: ending the life of the child even when it is perfectly possible to keep the child alive away from the mother.

Another interesting twist, occasionally raised in the past but only recently fleshed out in full, is to ask whether it is obvious that the body belongs only to the woman, as Christopher Tollefsen has recently done. One could extend this further: if the baby is alive in her natural habitat, and is being threatened by the mother, couldn’t someone else (e.g. the father) reasonably be enlisted to defend the baby against that lethal force? This is far from obvious. The self-defence argument works both ways.

Others have sought to show that there are obvious disanalogies between pregnancy and the violinist situation:

1. In the overwhelming majority of pregnancies, the woman bears some responsibility for the pregnancy. You needn’t say that consent to sex is consent to pregnancy; you just need to say that choosing to do something which leads you to have a human being dependent on you as a natural and not infrequent consequence gives you some responsibility for that dependent human being. In that case, Thomson’s argument at best works only in the case of rape (which is still, of course, a substantive and important result if true, but doesn’t work for the majority of abortions). As an example, drunk drivers bear responsibility for caring for someone if they have paralysed them, even if they took certain precautions to be careful. They did something that was inherently ‘dangerous’ and bear some responsibility. It is easy to see how this disanalogy has been seen as less forceful because it is so easy for men to abdicate their responsibility to their children. If men are allowed to have sex without the responsibility, surely women should as well? But as the drink-driving example suggests, the conclusion is not that women should be able to abdicate responsibility for an inherently risky activity – but that men should be forced to live up to their responsibilities.
2. In every case of abortion, the woman is the mother of the child. This presumably makes a big difference. Even if abortion is not killing, it is wrong to allow your child to die without handing responsibility to someone else – even if that means you have to look after your child for a period of time until it is possible to hand the responsibility to someone else.
3. In the case of the violinist, it is an unnatural situation: the violinist is not where he is supposed to be. He is not in his natural habitat. This is quite the opposite to the case of pregnancy, where the baby is exactly where she is supposed to be, in her natural habitat, living in the environment in which every other human being entered the world. Why think this is important? Well, for one thing, it suggests that the baby is not trespassing: if so, it will be much harder to justify using lethal force against her.
4. Perhaps the key difference is that disconnecting the violinist looks more like letting die than killing, and the rules on letting die and killing are very, very different. In Anglo-American law, letting people die is generally legal (though not always). But killing is almost never permissible – only in self-defence or in cases of ‘necessity’ (a complex matter almost never used, and dealt with in Greasley’s book). Given that abortion is typically killing, the standard defences to homicide do not work – it is not proportionate self-defence, and it is not necessary in the relevant legal sense. So there is another disanalogy with the violinist case. Greasley’s book argues this compellingly at significant length – from a pro-choice legal perspective.

Put this all together. Suppose the violinist case were different: you were drink driving one night and knocked over your daughter, who became dependent on you for several months. Would it be permissible for you to, for example, dismember her in the way that some abortions are performed? Obviously not. Nor would it be plausible that you could morally just ‘eject’ her from your house. You have a duty to her. And you certainly have a duty not to kill her. Hence, Thomson’s argument appears to fail.

It is often thought that the reason pregnancy ethics are so controversial is because we have no analogies: pregnancy is a unique situation, unlike anything else. This is mostly true, I think, but not entirely. Kate Greasley points out that conjoined twins can be in a very similar situation, but more ‘burdensome’ still. There are some cases of conjoined twins where one twin is entirely dependent on the other – not only for 9 months, but for the rest of their lives. Moreover, the independent twin did nothing (at least, not knowingly) to cause the existence or dependence of the other twin. Yet the law has been very clear that it would be completely impermissible – morally and legally – for an independent twin in such a situation to end the life of her sister by disconnecting her. I think this is right.

Let me close by saying a bit more about the ideological background here. The argument is deeply rooted in a profoundly individualistic view of the world, according to which it is very rare for people to have claims on each other simply because they are needy. One of the things Schouten describes so well is how deeply this conflicts with fundamental feminist norms – and I would also say, with progressive, welfarist norms (the topic of my paper). Many of us in the West now recognise that the invisible hand is sometimes not the fairest dealer – some of us are in situations of great power, and others in situations of great vulnerability. Rather than the ‘each to their own’, dog-eat-dog kind of liberalism which inspired Thomson’s article, many of us on the political left are moving towards a radically community-centred ideology, where people’s being in need means we have certain duties, as a society, towards them. I doubt many of us are compelled by the idea that we could just walk past homeless people, or refugees, insisting that while it would be nice to help them, they have no right  to our money and therefore we – and the state – can just neglect them to death. That surely isn’t how morality works. When we see a vulnerable person, we realise they have a claim on society – and that claim sometimes involves our personal labour on an individual level, sometimes very significant labour. Would it be better if society could distribute all the labour equally? Perhaps. But life doesn’t always throw us convenient problems. Sometimes doing the right thing takes considerable sacrifice, or even heroism.

For more on Thomson’s argument, see the work of Gina Schouten, David Hershenov, Kate Greasley (all linked above), and a forthcoming paper by Emma Wood (which I cannot yet find online).

“No one should be forced to be pregnant/give birth”

It is absolutely true that no one should be forced to become pregnant, and no one should be forced to give birth. This can occur in the case of rape, which is a heinous crime (see ‘What about abortion in cases of rape?’). In every other case, there is a choice not to become pregnant: pregnancy is a natural consequence of sex, and everyone (except in the case of rape) has the choice whether to have sex or not. The fact that we do not necessarily like this connection does not mean we can ignore it and then claim we have a right to escape the consequences, especially when escaping the consequences can only be done by violating the fundamental rights of another human being.

Almost everyone thinks that ‘forced pregnancy’ is OK in the third trimester, for example. Almost everyone thinks that women should be ‘forced to give birth’ late in pregnancy, because almost everyone supports a ban on very late abortions. In reality, the language of ‘forcing’ is an uncharitable way of framing the issue. Pro-lifers don’t think women should be forced to become pregnant. Nor do they want to keep women pregnant, or make them give birth, just for the sake of it. That is what the language used in this question implies. But in fact, they just think that ending a pregnancy by ending the life of a child is not permissible – just as most other things we are normally allowed to do would be off-limits if the only way to do them was by ending the life of a child. Suppose, for example, it is a winter’s night, and you are in your car. The only way you can get home tonight is by running over a small child – all the other roads are closed, and there is no way to remove this child. You must either stop where you are for the night or run the child over. You could frame this as ‘being forced to sleep out in the cold in a car’. And you could rightly say that ‘no one should be forced to sleep out in the cold in a car’. But this would clearly be uncharitable: the reality is that, because of the circumstances, the only way to avoid that consequence is by ending someone’s life. Likewise in the case of abortion.

“No one should be forced to be a mother”

The same considerations as in the last question apply. But in addition, on any plausible scientific view, the pregnant woman is already a mother. Even if you don’t believe the foetus is a ‘person’, it is scientifically beyond dispute that the pregnant woman is the mother of the foetus – which, of course, is Latin for ‘offspring’, to compound the point.

One additional major problem for this argument is that pro-choicers do think that men can be forced to be fathers. If a woman has a choice about whether to keep a baby, she can force a man to be the father by giving birth. This provides a dilemma: either we have to admit that people can be forced to be parents, or we should say that men should be able to force women to abort their joint offspring. This latter option is absurd. So it seems that women can ‘force’ men to be fathers. If so, then why can’t women be ‘forced’ to be mothers? Again, this only helps to reinforce what an uncharitable interpretation of the situation this terminology involves.

Is abortion self-defence?

It could be argued that abortion is permissible as a form of self-defence. Unfortunately, this doesn’t work for a variety of reasons most comprehensively explained by pro-choice Oxford legal scholar Kate Greasley. In short, it is questionable that the foetus could count as an aggressor. But most importantly, a key element of self-defence is that the threat is proportionate to the force used. In the case of abortion, the child is killed. Hence the threat to the mother must be sufficiently serious to warrant using lethal force. This is obviously not present in the overwhelming majority of abortions, except in those few where the mother’s life is genuinely at risk. And in those cases, pro-lifers do indeed agree that abortion may be allowed (though they disagree about whether to call it ‘abortion’).

How many abortions are there per year?

Why do abortions occur?

What proportion of women aborting are married?

What proportion of abortions are repeat abortions?

What proportion of abortions occur among women with children?

What proportion of abortions occur among ethnic minority women?

At what gestation do abortions occur?

What does abortion involve?

Is abortion killing?

Is medical abortion just a heavy period?

Which disabilities are abortions performed for?

Is sex-selective abortion a serious problem?

Is abortion on demand legal?

How many abortions are there per year?

In the UK, there are just over 200,000 abortions a year, an increasing trend. In the US, there are around 800-900,000, a decreasing trend. Around 1 in 3, or 1 in 4, women are estimated to have an abortion in their lifetimes in these countries. That is a huge number of people affected by abortion.

There is considerable variation in the abortion rate between different pro-choice countries. The WHO keeps data on abortion rates in pro-choice European countries, by abortions per 1,000 live births. By 2016, Croatia had the lowest rate at 67, followed by Slovakia on 105 and Switzerland on 115. Bulgaria was highest at 406, with Russia at 355 and Estonia at 328 (Romania and Moldova were higher but no data were available in 2016). In general, rates were higher in many (though not all) former Soviet bloc countries, and in Northern Europe, with lower rates in central Europe and the Mediterranean (Poland and Ireland did not have legal abortion at the time, along with a few other smaller countries; data for Austria, Turkey, and some smaller countries were unavailable).

This raises the question of factors affecting the abortion rate. This will be covered under ‘How to reduce the abortion rate’.

Globally, it has been claimed that there are now over 70 million abortions year. This is almost certainly a significant overestimate, since estimates of abortion in countries where abortion is illegal are based on the Abortion Incidence Complications Method, which has a number of substantial problems (see ‘How many abortions occur when abortion is illegal?’). Nevertheless, it is evident that there are tens of millions abortions globally per year.

Fortunately, the UK collects good data on the basic reasons for abortion, as a legal requirement, along with data on gestational age, previous abortions, age of the mother, and so on. Although these will obviously differ between countries, the UK offers a helpful baseline, especially for the much-discussed cases such as foetal disability, late-term abortions, and so on.

Why do abortions occur?

The UK only allows abortion in accordance with specified grounds, though these grounds are so vague that one (or maybe two) effectively allow abortion on demand. For grounds 1 and 2 here, abortions are allowed up to 24 weeks. For the other grounds, including disability, abortion is permitted up to and during birth. The number of abortions for each legal justification are as follows:

1. Abortion for physical or mental health: 205,930 abortions. 99.9% of these were classified as F99 (mental disorder, not otherwise specified – the catch-all ‘diagnosis’ allowing abortion for any reason at all)
2. Abortion for the physical or mental health of ‘existing’ children: 776 abortions
3. Abortion for a ‘substantial risk’ that the child would be ‘seriously handicapped’: 3,083 abortions
4. Abortions because the pregnancy poses a greater risk to the life of the woman than abortion: 91 abortions
5. Abortions to prevent ‘grave permanent injury to the physical or mental health of the woman’: 30 abortions
6. Abortions to save the life of a woman, or prevent grave permanent injury to a woman, in an emergency situation: 7 abortions

This is illuminating in various ways. It can be seen that only a tiny percentage of abortions are to save the life of a woman or prevent grave permanent injury – 128 at most. But in fact, because of the phrasing of the Act, these do not need to be situations where the woman’s life is at risk. The risk of death just needs to be higher than that of pregnancy – it could still be a miniscule risk. Abortion on demand was provided under this ‘life-saving’ clause for many years by some clinicians. Freedom of Information data confirm that a significant proportion of these 98 abortions did not involve situations where abortion was medically necessary. Very few occur – less than 0.01% – occur for other physical health reasons.

Likewise, relatively few abortions occur because the child has a disability – around 1.5% of the total. More statistics about these will be discussed elsewhere.

The overwhelming majority of abortions are performed under the ‘mental health’ clause, and it is widely agreed that this includes abortion for virtually any reason, including sex-selective abortion (see ‘Is sex-selective abortion a serious problem?’ and ‘Is abortion on demand legal?’).

These statistics do not say much about the specific reasons women have abortions, however. Studies from elsewhere confirm that when socioeconomic reasons are explicitly allowed, very few women cite mental health as a reason for abortion. Statistics across a wider range of countries suggest that the primary motivations are family size and spacing preferences, career and educational reasons, and economic concerns. Clearly, all of these can admit of varying degrees of seriousness.

Abortions resulting from rape will be addressed under ‘What about abortion in cases of rape?’

What proportion of women aborting are married?

In the UK in 2020, 17% of abortions were among married women. 23% were among single women with no partner, 51% among single woman with a partner, 7% were single and unstated, and 2% separated/widowed/divorced. These numbers obviously vary considerably by age group.

13% of abortions among 20-35 year olds were among married people, while around 28% of 20-35 year old women were married, giving a small confirmation that marriage is linked with lower abortion rates. Similar results are shown in American data.

What proportion of abortions are repeat abortions?

The UK 2020 data show that 42% of abortions were repeat abortions, meaning that the woman had previously had at least one abortion.

30% had previously had one abortion, 9% had had two abortions, 2% had had three abortions, and 1% had had 4 abortions previously. 131 individuals had had 8 or more previous abortions.

What proportion of abortions occur among women with children?

The UK 2020 data show that 58% of abortions occurred among women who had previously had a live birth or stillbirth.

What proportion of abortions occur among ethnic minority women?

The UK 2020 data show that 77% of abortions occurred among women identifying as White, 4.5% among women identifying as Mixed, 8.6% among women identifying as Asian, 7.4% among women identifying as Black, 0.6% among women identifying as Chinese, and 1.6% among women identifying as Other.

For comparison, around 3.9% of 18-24 year olds in the UK identify as Black, but 6.9% of abortions in the equivalent age group were among women identifying as Black. Likewise, 2.7% of 18-24 year olds in the UK identify as Mixed ethnicity, but 4.4% of abortions in the equivalent age group occur among women identifying as Mixed ethnicity. These figures suggest that abortion disproportionately reduces Black and Mixed ethnic populations. Similar figures hold in the US.

At what gestation do abortions occur?

The trend has been towards earlier abortions, though in recent years gestational estimates have been less reliable due to the trend away from examination and ultrasound prior to abortion. Since abortion has been available by telemedicine in early 2020, gestation has been measured by the time pills were sent, rather than the time they were taken (later), misleadingly skewing the results towards earlier abortions. It is known that some abortions happen many weeks later than recorded as a result of telemedicine (see my chapter on telemedicine).

Officially, 82% of abortions are under 9 weeks, 11.8% are between 9-12 weeks, 5.0% are between 13-19 weeks, 1.2% are between 20-23 weeks, and since the law becomes stricter at 24 weeks, 0.1% beyond 24 weeks.

It is undeniable that most abortions are early in pregnancy. But the numbers for late and very late abortions are hardly a relief to those who have moral concerns about abortion at later stages. Many people who are generally pro-choice still think that abortions at late stages, or very late stages (say, beyond 12 weeks or beyond 20 weeks), are tantamount to murder. If so, it is hardly consolation that the percentage of abortions which are murder is very low. The fact that there are tens of thousands of abortions which are morally permissible is hardly a reason not to worry about the 13,000 which occur beyond 13 weeks, or the 3,000 which occur beyond 20 weeks (in the UK each year).

Nor can it be argued that these late abortions are for rare cases. In fact, the empirical evidence suggests that for the most part, women obtaining abortions later in pregnancy are having abortions for the same reasons as women having abortions earlier in pregnancy, because the main delay was in identifying the pregnancy. This is confirmed by the UK data, which show that even after 20 weeks (viability is now coming down to around 21 weeks), the majority of abortions are for ‘mental health’ reasons (though a much bigger minority are for foetal disability, which is only diagnosable later  in pregnancy).

What does abortion involve?

There are two broad kinds of abortion: medical and surgical. The balance of medical and surgical abortions differs significantly from country to country. In much of Europe, medical abortion is more common, but in the US and a few other countries, surgical abortion is much more common. From around 10 weeks, surgical methods are more common than medical, even in countries with mostly medical abortion. Medical abortion is much more common for illegal abortions since mifepristone and misoprostol became an accepted method of abortion, and widely distributed. This has significantly reduced the risks of illegal abortion, to the point that illegal abortion by this method is widely considered safe (though still with risks, as with all abortion).

Medical abortion

Medical abortion is broadly similar throughout pregnancy. It typically involves administration of a pill called mifepristone, which blocks progesterone receptors and thereby makes the uterus less hospitable to pregnancy in various ways, depriving the baby of oxygen and nutrients. Sometimes this kills the baby; sometimes it does not. Then, misoprostol is given. This essentially causes a miscarriage; the uterus contracts and the baby is expelled. If the mifepristone has not killed the baby, the misoprostol usually does, in the process or sometimes shortly after the baby has been miscarried, with the baby sometimes visibly moving after being delivered. Sometimes the baby dies from prematurity after expulsion.

Of course, if the medical abortion takes place after viability, there is a chance the baby could survive outside the womb if given medical treatment. In many countries, such as the UK, there becomes a legal obligation to rescue the baby, though in some countries the baby is left to die even if viable (sometimes seemingly contrary to the law, as in the UK) – the US Senate has attempted to ban this form of passive infanticide on many occasions but thus far failed.

To prevent the ‘problem’ of the baby surviving arising, a procedure is first performed for babies beyond the point of viability. This procedure is technically called ‘feticide’ – meaning ‘killing the offspring’, from Latin. Feticide ordinarily involves injecting a lethal chemical, usually potassium chloride, directly into the baby’s heart, to stop it. The use of potassium chloride for capital punishment has been widely protested as inhumane by human rights groups, because it is so excruciatingly painful. Its use is prohibited as a means of putting down any conscious vertebrate by veterinary associations worldwide. When it emerged that this procedure was being performed in Ireland after the legalisation of abortion, academic journals reported that feticide practitioners themselves described it as ‘brutal’ and ‘awful’, as ‘stabbing the baby in the heart’, with one ‘getting sick out in the corridors afterwards because I thought it was such an awful procedure’. Another paper reports one practitioner as saying, ‘a lot of people wouldn’t even know that feticide happened… a lot of people might be quite shocked… My partner is anxious that it doesn’t become too widely known… clearly some people will find the whole thing abhorrent.’

Overall, in the UK, 85% of abortions are medical, and of these, around 900-1000 babies are killed by feticide (sometimes before induction of labour – medical abortion – and sometimes before very late surgical abortion).

Surgical abortion

Surgical abortions differ depending on the gestation of the pregnancy, since the baby’s size and toughness make earlier methods difficult after around 13 weeks.

Up to around 13-14 weeks, vacuum aspiration is generally used. This involves sucking the baby out with a vacuum, killing it in the process. Formerly, a technique called dilation and curettage was used. This is generally discouraged because it is associated with increased risks, including placenta praevia and Asherman’s syndrome, as well as increased pain and bleeding. However, D&C is still widely used in many countries.

From 13-14 weeks (sometimes earlier), the baby is usually too big and tough to be removed by vacuum, so dilation and evacuation is usually used. Even in countries with predominantly medical abortion, D&E is the most common method of later abortions from around 15 weeks (vacuum aspiration is the main method from 10-14 weeks).

D&E involves dismembering the baby limb by limb with forceps. The baby’s skull is crushed in some cases, if it is too big to be removed intact (here and here). In this method, the baby must be pieced back together again outside the womb to ensure that it has all been removed.

Intact dilation and extraction (D&X), also known as ‘partial birth abortion’, was used in the US until it was federally outlawed in the 00s. The inventor of the method noted that ‘Classic D&E is accomplished by dismembering the fetus inside the uterus with instruments… However, most surgeons find dismemberment at twenty weeks and beyond to be difficult due to the toughness of fetal tissues at this stage of development’.

The author then described a new method. After delivering the baby in breech position (legs first), so that everything except the head is delivered:

‘the surgeon takes a pair of blunt curved Metzenbaum scissors… the surgeon then forces the scissors into the base of the skull… having safely entered the skull, he spreads the scissors to enlarge the opening. The surgeon removes the scissors and introduces a suction catheter into this hole and evacuates the skull contents. With the catheter still in place, he applies traction to the fetus, removing it completely from the patient.’ (Martin Haskell MD, “Dilation and Extraction for Late Second Trimester Abortion”, presentation at the National Abortion Federation Risk Management Seminar, 1992.)

That is to say, when the baby is almost entirely delivered – the doctor forces scissors into the baby’s skull and sucks its brain out with a catheter. This is the specific event which kills the baby. It was generally used late in pregnancy when the baby was clearly able to feel pain.

The procedure was outlawed in the US, but remains legal in the UK. It is unknown whether it occurs in the UK, but there is a consensus that it is legally permitted (as in many other countries). While it was initially claimed that very few partial birth abortions took place, and only in extreme circumstances, a proponent of the method later admitted in the media that this was a lie, and that it was usually used on healthy babies with healthy mothers.

Other methods of abortion have been used in the past, but are rarely used now. For example, saline abortions used hypertonic saline (salt water) to dehydrate the baby and derange its electrolytes such as sodium. This could cause death by dehydration, cardiac arrest, or otherwise. Pictures of the effect of the hypertonic saline on the skin of the baby are easily available online. Alternatively, hysterotomy abortions use a similar procedure to a caesarean section, with the baby being killed by feticide beforehand or being left to die (or smothered, thrown away, or drowned, in various historical cases) once removed from the womb. Saline and hysterotomy abortions are now rare.

Typically, even late abortions do not involve painkillers for the baby. Painkillers for very late term abortions are routine in France, but not in many other countries, like the UK or USA, in part as a vestige of the outdated and misleading guidance from the RCOG. Indeed, abortion groups vigorously protest attempts to mandate painkillers for late-term abortions, at which point the baby undeniably feels pain. By contrast, fetal analgesia is used for fetal surgery, when babies are operated on before birth. And certain national laws (for example, the UK’s Animals Act 1986) require the humane killing and treatment of any mammal, reptile or bird in the final third of pregnancy. Human foetuses are the only exception.

Is abortion killing?

To kill means, roughly, to end a life. Abortion clearly does this, and in more candid moments this will be conceded by abortion advocates and practitioners. An obvious example is that late abortion involves ‘feticide’, which literally means ‘killing the offspring’. The RCOG guidance on feticide says that ‘failure to perform feticide could result in a live birth and survival, which contradicts the intention of the abortion’. Elsewhere they say that ‘Intrauterine fetal death refers to babies with no signs of life in utero’ – presumably in contrast to ‘babies’ who do show signs of life in utero, who are alive. The prestigious Cochrane Library defines miscarriage as ‘the spontaneous death and/or expulsion of an embryo or fetus from the uterus before it is able to survive on its own’, and the National Institute for Clinical Excellence, the leading clinical guidance body in the UK, says that ‘Intrauterine fetal death is when an unborn baby (fetus) dies inside the womb before birth’. Ann Furedi, until recently the CEO of the UK’s leading private abortion provider, defines abortion as ‘the intentional destruction of the fetus in the womb, or any untimely delivery brought about with intent to cause the death of the fetus’.

Hence, it is uncontroversial from a medical point of view that abortion involves ending a life, and hence is killing.

Is medical abortion just a heavy period?

After the recent shift towards medical abortion rather than surgical abortion, there has been an attempt to sanitise it by describing it as simply a ‘heavy period’. This is neither accurate nor reflective of how women experience it. Studies show women frequently feel unprepared for the amount of pain, bleeding, and seeing the visible human embryo or foetus, which can sometimes move after it has been expelled.

Of course, all abortion ends a life, so it is obviously far more significant than a period in that sense. Medical abortion also has a significant complication rate – far more so than a period and significantly more so than surgical abortion (see ‘Immediate complications of abortion’). Finally, as we will see, women are frequently misled about the experience itself.

The UK’s leading clinical guidance authority, NICE, released an evidence review of what women need to know prior to an abortion. It identified significant evidence from various studies about what women were told about pain, bleeding, and the embryo/foetus compared to what they experienced. Notably, many of these comments were even for very early medical abortions, before 9 weeks:

‘I kind of thought that I’d go there, bleed a little and then go back home, having it all done. But I learned that wasn’t the case.’ – 17-year old, first time pregnant.

‘There wasn’t enough information about the bleeding and the pain, I thought. The bleeding was massive. It was very frightening.’

‘Most of the women experienced the abortion with a bleeding that was larger than they were prepared for.’

‘I put a paper in the toilet so I would see that I had aborted… was totally unprepared for seeing the embryo… became very sad… I could clearly see that it would be a human being.’

‘You could see fetus, where the ears were, the arms, I was really frightened.’

‘In hindsight I wish I hadn’t looked but I did, and that was probably the most traumatic thing I’ve ever seen or done. I thought ‘what on earth…?’

‘Many participants undergoing medical terminations had not expected the procedure to last for as long as it did: ‘Nobody told me how long I might be in the labour ward for (I was told 6-12 hours and I was there for three days which I later found out was quite common)’.’

NICE found that ‘There was evidence that women wanted information about what to expect when viewing the pregnancy. The committee agreed this was important, that women should be aware that the pregnancy may be more identifiable after 9 weeks’ gestation and that there may be movement at later gestations’. In the final guidelines, they recommended that ‘For women who are having a medical abortion, explain:

• that they may see the products of pregnancy as they are passed
• what the products of pregnancy will look like and whether there may be any movement.’

While medical abortion often kills the baby by detaching it from endometrium, thereby depriving it of oxygen and nutrients, it has a variety of mechanisms (best summarised here). Sometimes it fails to kill the child by itself, and the child is then killed by the trauma of being squeezed by the contracting uterus and expelled from her mother’s body. Sometimes the child survives both of these and dies of the various difficulties of prematurity (or sometimes lack of care, or indeed survives, if after 21 weeks). As noted in ‘What does abortion involve?’, at later stages it requires feticide first.

There is more to be said (Skop has a helpful overview) but it is clear that women are frequently misled about the experience of medical abortion, and of course, all abortion ends a human life.

Which disabilities are abortions performed for?

The UK has recently stopped publishing the primary medical condition cited for disability-selective abortion, making the statistics more difficult to discern (since multiple conditions can be recorded and it is unclear which is the main reason). However, 2018 statistics did include primary medical condition, so these will be used.

In this year, 3,269 abortions for disability occurred. 1,079 were for chromosomal conditions, mostly Down Syndrome (618) and Edwards’ Syndrome (228). 696 were for neurological conditions, particularly anencephaly (203), a condition where the cerebral hemispheres do not develop at all or develop only partially (this means it is on a broad spectrum and some children can live a significant amount of time), and spina bifida, where the spine does not form properly, again, with a wide variety of severity. 895 were for other congenital malformations including cleft lip and cleft palate (generally easily correctable conditions), genital malformations, some very serious cardiovascular conditions, and a wide variety of others. 599 were for a wide variety of other conditions, including ‘selective reduction’ for multiple pregnancies, where one or more babies are killed and one or more babies are allowed to live.

Pressure to abort babies in these situations has been widely reported, with some mothers reporting how they even had abortions scheduled by the doctor without asking or agreeing. Abortion is legal up to birth if the child is disabled in many countries, including the UK. Mothers have been guilt-tripped into having abortions, and told that they can change their mind and have an abortion at any point, even a few days before delivery.

Disability-selective abortion, also known as eugenic abortion, has been widely criticised by disability rights group for discriminating against disabled people, in the same way that sex-selective abortion does. Even the UN Committee on the Rights of Persons with Disabilities has criticised the practice and urged countries to remove laws permitting it.

Disability-selective abortion has led to huge reductions in the number of people with disabilities – not by treating or curing their disability at the request of them or their parents – but by ending their lives before birth. This has led to up to 90% of babies with Down Syndrome being aborted in the UK, and reportedly 100% in some other countries like Iceland.

I have a paper in progress on the topic of disability-selective abortion which will be available in due course.

Is sex-selective abortion a serious problem?

The overwhelming majority of pro-choice people still support some restrictions on abortion – one of those is sex-selective abortion, where a baby is aborted solely on the basis of their gender. In the UK, 91% of women think sex-selective abortion should be explicitly banned, with only 4% opposed.

Globally, this problem appears to be worsening. In India alone, there are thought to be 13.5 million missing girls due to sex-selective abortion – or perhaps as many as 22 million. The sex ratio at birth (used as a measure of sex-selective abortion) for China has been even worse for the last few decades. This means that, on a global scale, abortion is one of the most powerful tools the patriarchy has for eliminating the voice, visibility and even the presence of women. In some areas, this problem is particularly severe: it was reported that in 132 villages in Uttarkashi, 216 children were born over a three month period – and not a single one was a girl.

The sex imbalance caused by sex-selective abortion – which almost always selects girls, not boys, for abortion – has caused further downstream problems, such as women and girls being trafficked as brides or sex slaves.

Sex-selective abortion is known – though not on the same scale – in so-called developed nations. In 2012, the Canadian Medical Association Journal reported that Canada had become a ‘haven’ for sex-selective abortion because of its relaxed abortion laws – in Canada, abortion is legal at any point for any reason.

In 2018, it was found that sex-selective abortion was a significant problem in the UK, in particular due to earlier screening tools (non-invasive prenatal testing). An earlier investigation had found that 1,500-4,700 girls were missing in the UK as a result of the practice. In response to the recent findings, the Labour Party called for legal restrictions: the Shadow Minister for Women and Equalities said that ‘the government needs to look into this exploitative practice and enforce appropriate restrictions’. But just 3 years prior, the Labour Party overwhelmingly voted against a ban on sex-selective abortions, with considerable support from parts of the Conservative Party.

Although some claim that sex-selective abortion is not legal in the UK, and used this as a reason to vote against banning it (a bizarre rationale even if true), it is widely agreed that sex-selective abortion is legal. If a woman says that having a baby girl would adversely affect her emotionally, there is little to stop her from obtaining an abortion on ‘mental health’ grounds, especially if her doctor approves. The practice certainly does occur in the UK. The leading research team on this topic in the UK warned that ‘Any attempt to explicitly criminalise SSA would likely jeopardise Bangladeshi, Indian and Pakistani women’s access to abortion care’ – that is to say, sex-selective abortion in the UK is a real phenomenon that – apparently – needs to be protected.

Is abortion on demand legal?

Of course, abortion on demand is not legal in many countries. But some people doubt whether abortion on demand – including, for example, sex-selective abortion – is legal in countries like the UK, where abortion is ostensible available only for health reasons.

Despite the seemingly restrictive law in places like the UK, ‘mental health’ is often interpreted as including abortion for any reason at all. In practice, in the UK, a reason is given, the woman is asked whether this would affect her emotional health, and if so, it is typically authorised. Typically, abortion providers will explicitly say to clients that they will authorise abortion for any reason except sex-selective abortion. However, as we have seen in the question on sex-selective abortion, even sex-selective abortion is widely held to be legally permissible.

Another way that seemingly restrictive laws can be interpreted as abortion on demand is through a ‘life-saving’ clause. UK law says that abortion is permissible at any point in pregnancy if two doctors believe, in good faith, that the pregnancy poses more risk to the life of the woman than an abortion would. The risk does not need to be high – just higher than the risk of pregnancy, around 1 death in 10,000 pregnancies. Since many doctors claim that abortion is less risky still, this would authorise abortion on demand for any reason even up until birth. Although this clause is not routinely used in this way in the UK now, it has been in the past.

This means that any country allowing abortion for mental health reasons, or health reasons with no further specification, is at risk of permitting abortion on demand.

When does life begin?

“No one knows when life begins”

What about foetal development?

When is the first heartbeat?

When does consciousness begin?

When can babies feel pain?

When is viability?

Which terminology is most accurate?

Is the foetus a parasite?

Does twinning suggest life doesn’t begin at fertilisation?

When does life begin?

As explained in ‘Why pro-life?’, this is a scientific question. 81% of laypeople say that biologists are the experts to answer this question, and ‘life’ is clearly a biological concept. But perhaps the reason there is some disagreement in the general public is because the question as phrased is somewhat ambiguous. There is a sense in which ‘life’ is continuous – life has existed ever since the first living creature. When an embryo is created, what existed before it was still ‘alive’ – the egg and the sperm cell, for example. Moreover, all sorts of things are alive but not persons – bacteria, for example. Even some human life is not morally valuable in the same way – an individual skin cell, for example. So we should be clearer about what it means to talk about the ‘beginning of life’.

What we really want to know is: when does ‘one of us’ begin to exist – a human being? Since a human being is an individual member of the species Homo sapiens – an individual organism of that species – what we are really asking is, when does an individual human organism begin to exist?

This makes it clearer still that it is a biological question. You might say: I don’t care when a biological human being begins, I want to know when a person begins – but that is just to deny that all human beings are persons, which is a different objection to the pro-life view (see ‘Why pro-life?’). It should not stop you from recognising the basic biology: that there is an individual human organism – a human being – from fertilisation.

In support of this claim, I repeat from ‘Why pro-life?’:

The claim is that human embryos and foetuses are human beings, that is to say, members of our species, Homo sapiens. They are individual human organisms – dependent, but still individual. They (usually) have their own genetic constitution and their own future. They have all they need to develop into a mature human being, other than nutrition and a normal environment. They need these latter two – but so do infants and toddlers, who will also die without nutrition, oxygen, or the care of others.

Bear in mind that no religious scriptures talk about fertilisation; fertilisation was only discovered in recent centuries. So the idea that a new human organism originates at conception is not grounded in religious tradition. On the contrary, it was a scientific discovery in the late 19^th century. It was precisely these scientific developments in the 19^th century which led to laws prohibiting abortion during this period – and these laws were promoted first and foremost by the medical profession.

That a human organism is created at fertilisation has remained a scientific fact ever since. It is taken for granted in countless works of embryology. A recent survey of 5 and a half thousand biologists from around the world found that 95% affirmed the view that a human organism is created at fertilisation, with the large majority of explicitly ‘very pro-choice’ biologists affirming this view. When people say that they are not human beings, they are more likely making the claim that they are not persons. That they are human beings is not seriously contested from a biological perspective (and 81% of laypeople surveyed in the same paper said that biologists are the experts on ‘when life begins’, so the biological perspective is clearly what most people have in mind when they talk about the beginning of life. As Ann Furedi, former CEO of the UK’s leading abortion provider, put it:

‘We can accept that the embryo is a living thing in the fact that it has a beating heart, that it has its own genetic system within it. It’s clearly human in the sense that it’s not a gerbil, and we can recognize that it is human life … The point is not when does human life begin, but when does it really begin to matter?’

For a more thorough discussion of these claims, see Condic (or here) or George and Tollefsen.

See also my published paper on this topic, with Alexander Pruss, along with my other academic papers here: https://calumsblog.com/academic-papers/. It comes at the topic from a slightly different angle (responding to a specific objection that there is no change of identity at fertilisation) but may still be helpful.

“No one knows when life begins”

As suggested in the previous answer, this is not true. We do know. The genuine question is whether all human beings are persons – individuals with full moral status.

Hence, the opinion of the US Supreme Court in Roe v Wade (1973) was clearly mistaken insofar as it depended on this claim: ‘We need not resolve the difficult question of when life begins. When those trained in the respective disciplines of medicine, philosophy, and theology are unable to arrive at any consensus, the judiciary, at this point in the development of man’s knowledge, is not in a position to speculate as to the answer.’

These professions are only uncertain because of the ambiguity of ‘the beginning of life’. When the question is actually clarified – the beginning of an individual human being – biologists have had an answer for around two centuries.

Consider another implication of suggesting that we ‘don’t know’ when life begins, and therefore we should let people decide for themselves. Wouldn’t it allow some people to say that life does not begin until a child is rational – several years into their life? Or even that it does not begin until the brain is fully developed, at around age 25? Why should we prevent people from performing infanticide, if they sincerely believe that life has not begun at that point, as many cultures throughout history have done?

Clearly, there is no problem with imposing one view of ‘when life begins’ over another. We already do so in the case of infanticide. That is because we do, in fact, have knowledge about when life begins. We know it begins before the infancy stage of human development. In fact, we know that it begins at fertilisation.

What about foetal development?

For an overview of foetal development, see my book chapter on the topic, which will be continually updated over time.

I also highly recommend https://www.ehd.org/ as a fully referenced summary of foetal development. It also has live videos of embryos inside the womb from around 4-8 weeks (some longer clips available here). In the videos section of my website I have collected together a few relevant videos as well.

NB: there is a difference of 2 weeks between gestational age (since last menstrual period) and embryological age (since fertilisation). Hence, if you see a discrepancy of 2 weeks between a claim of mine and the reference cited, this is the reason.

When is the first heartbeat?

It has recently been suggested that this is a contentious issue, in the light of ‘heartbeat bills’ in the US banning abortion from the time a foetal heartbeat is detectable. This is dishonest, because there is no real controversy within the scientific community. The first heartbeat occurs at around 22 days after fertilisation, and this is standardly recognised without hint of controversy. For example, in 2020, researchers from the University of Oxford’s Division of Cardiovascular Medicine, noted in their basic introduction to cardiovascular embryology that ‘The initiation of the first heart beat via the primitive heart tube begins at gestational day 22, followed by active fetal blood circulation by the end of week 4’.

In fact, the University of Oxford recently announced research suggesting that the first heartbeat was even earlier, perhaps as early as 16 days (original paper). Again, the researchers displayed no hesitation about calling this a ‘heartbeat’. In fact, even Planned Parenthood, at the forefront of heartbeat denial, describe this as a ‘beating heart’ on their website.

It is claimed that this is not really a heart or a heartbeat, but ‘a grouping of cells that are initiating some electrical activity’. But for those who may not have gone to medical school, that is essentially what a heart and a heartbeat are. The heart is composed of cells, which initiates some electrical activity (from the sinoatrial node), which causes the heart to contract, i.e., pump. Presumably the pumping was left out of this account because some people might realise that this sounds a little too much like a heartbeat.

Secular Pro-Life has a helpful collection of articles about this recent instance of science-denial by the more extreme wing of the pro-choice movement, including this article. My favourite example (described in full here) is when a proponent of this pseudoscience backed up her somewhat hubristic article by saying that ‘Any basic embryology textbook’ explains the formation of a zygote at fertilisation, not a foetus. Unfortunately, the ‘basic embryology textbook’ she chose to cite was yet another textbook confirming that ‘The heart begins to pump fluid through blood vessels by day 20’.

In summary, the human heart begins to beat probably between days 16-22 after fertilisation. To say otherwise can only be described as pseudoscience. We should, in fact, be appalled that certain medical authorities are colluding in this deception.

When does consciousness begin?

Obviously, no one really knows when consciousness begins. Even attributing consciousness to other adult humans involves some philosophical assumptions, though most of us are confident in the case of human adults. When it comes to animals, we are far less confident, mainly because we know so little about what, exactly, causes consciousness. This is a philosophical problem as much as anything. Although there is no reasonable doubt that foetuses are conscious by the early third trimester, and there is no longer much reason to doubt that they are conscious in the second trimester, whether they are conscious in the first trimester is extremely difficult – if not impossible – to assess.

The baby’s first non-reflexive movements – indicating substantial neurological development – begin at just 4-5 weeks after fertilisation, reflexive movements beginning shortly after. Brain waves are detectable from 43-45 days at latest (and perhaps earlier). From 12 weeks, babies can make purposeful movements towards their twin, taking special care around their twin’s eyes. Further details of landmarks later in pregnancy are available in my book chapter, but in my view the purposeful movement towards their twin is sufficient evidence for us to be relatively confident that babies 12 weeks after fertilisation (14 weeks’ gestational age) are conscious.

It is sometimes thought that the embryo does not look human in the first trimester. This is not really true, but in any case, one of the main differences between embryos and adults is one of proportion. The embryo’s head is, after a few weeks, enormous compared to the rest of its body. But that is precisely because the brain is so big. By 8 weeks, the brain is 43% of the baby’s bodyweight, and by 11 weeks, the forebrain alone has 3 billion neurons.

The evidence that babies can feel pain as early as 10 weeks from fertilisation is also relevant, since it is only possible to feel pain if one is sentient.

When can babies feel pain?

It is virtually certain that babies feel pain by 23 weeks after fertilisation (21 weeks since fertilisation). See the videos section of this website for videos of babies at 23 weeks, and 28-34 weeks, responding to an anaesthetic injection. In my view, it is not possible for any sane person to doubt that these babies are experiencing pain.

The Royal College of Obstetricians and Gynaecologists claim that it is doubtful whether babies even by this point feel pain, since they would be too heavily sedated by the ‘warm, buoyant and cushioned’ environment, and chemical factors like adenosine. But it is obvious that the babies in these videos are not sufficiently sedated by these factors. I work in surgery. If a supposedly anaesthetised patient made these facial reactions in response to an injection, we would quickly conclude that they were very much awake.

The RCOG also claim that pain is not possible at all before 24 weeks, since connections from the periphery to the cortex are not intact, and the cortex is needed for pain sensation. Of course, this claim is also straightforwardly disproven by the 23 week fetus in the video which clearly has a cortical response to a painful stimulus. But perhaps we can allow a small margin of error.

A more problematic development for the RCOG is that one of the lead authors of the report, Stuart Derbyshire, who is the world’s leading authority on fetal pain, and himself still pro-choice, has since changed his mind and believes that pain may now be possible from 12 weeks’ gestation (10 weeks after fertilisation). He says that despite claims of a consensus, ‘there never was a consensus that fetal pain is not possible before 24 weeks’, noting many papers which have ‘speculated a lower limit for fetal pain under 20 weeks’ gestation… Regardless of whether there ever was a consensus, however, it is now clear that the consensus is no longer tenable.’

Derbyshire and his co-author, John Bockmann, make two primary points: first, there are in fact functional projections from the thalamus to the cortical subplate from 12 weeks, which are equivalent to later thalamocortical projections (previously thought to be necessary for conscious experience of pain). Moreover, however, the authors doubt whether even the cortex is needed for pain sensation, noting a case of preserved pain sensation in a patient in whom the cortical areas normally thought necessary for pain were almost entirely destroyed. In addition, others have noted that many children with anencephaly or hydranencephaly, in whom the cortex is absent or almost absent, are clearly sentient and able to feel pain. Given that the primary objection to fetal pain prior to 24 weeks has been the necessity of thalamocortical projections, it appears there is no longer any good reason to doubt the possibility of pain prior to this point. Hence, fetal pain may well be possible from 12 weeks or earlier.

Other authors have suggested the possibility for pain even earlier.

When is viability?

Viability – the point at which a baby can survive (with medical assistance) outside the womb – obviously differs enormously depending on place and time in history. The graph shown here demonstrates the proportion of babies surviving at <1000g (around 28 weeks, usually) at given times in history. Clearly there was a huge improvement in the second half of the 20^th century, which has persisted to this day. Although viability is now often assumed to be 24 weeks, in reality babies have survived much earlier, with the record holder being Curtis Means, born at 21 weeks and 1 day. In fact, survival rates at 22 weeks are not at all bad: a recent systematic review found that survival rates when 22 week babies are actually given treatment is around 43.6%. For this reason, clinical guidelines are gradually moving towards standardly considering resuscitation for babies born at 22 weeks, who would previously have been thought to have no hope and so left to pass away peacefully.

Which terminology is most accurate?

Pro-choicers often criticise pro-lifers for using ‘inaccurate’ or ‘unscientific’ language when they, for example, call the embryo or foetus a ‘child’ or ‘baby’.

This is highly misleading (or false). It is a confusion between inaccurate terms and non-technical terms. Non-technical terms can still be perfectly accurate – ‘axilla’ is the technical term for ‘armpit’, but ‘armpit’ is still perfectly accurate, and doctors use it all the time. Likewise with ‘myocardial infarction’, the technical term for a heart attack.

The reality is that doctors and academics (I am unfortunate enough to be a member of both categories) frequently use the term ‘child’ or ‘baby’ for a human foetus.

Take the term ‘child’, for example. This is, in fact, an accepted term in international law – there is a Convention on the Rights of the Child. And that Convention states clearly in its preamble that children need legal protection ‘before, as well as after, birth’. Hence in international law there is such thing as an ‘unborn child’. This is impossible to dispute. Likewise, in medicine, the foetus is often referred to as a child. The Oxford Handbook of Obstetrics and Gynaecology has no hesitation about referring to the ‘unborn child’ on multiple occasions. For example: ‘it is considered unethical to deny treatment to an HIV +ve mother as this treatment would protect her unborn child and potentially her own health.’ The simple reality is that it has never been unacceptable or inaccurate to refer to the foetus as an ‘unborn child’ within law or medicine.

Likewise with the term ‘baby’, which the same textbook refers to on various occasions, as does the NHS website. If you’re really in doubt, simply search ‘unborn baby’ or ‘unborn child’ on Google Scholar, and see how many results come up. In fact, a recent systematic review in one of the leading Midwifery journals concluded that “Midwifery scholarship, global midwifery professional bodies position statements and practice codes mostly employ the word ‘baby’ instead of ‘fetus’.”

The idea that ‘unborn child’ or ‘baby’ are ‘unscientific’ terms is, frankly, absurd. These terms are used constantly in clinical practice, and often in academic and medical textbooks as well. The attempt to remove them from terminology looks more like politically motivated euphemism than serious science or linguistics.

Is the foetus a parasite?

No, this claim is absurd and dehumanising. The use of ‘parasite’ language to describe undesirable human beings has an unpleasant history (to put it mildly) and we should be very careful before wielding it to speak about any humans ever again.

In fact, however, research suggests that, in general, pregnant women have a significantly lower risk of death than non-pregnant women (see ‘Abortion is 14 times safer than childbirth’), and the unborn child shows substantial symbiosis with the mother: for example, sending its stem cells around the mother to repair tissue and act as surveillance cells against various cancers.

No biologist refers to pregnancy in general as parasitism. But if an unwanted pregnancy is parasitism, it is hard to see how all pregnancies shouldn’t be: all pregnancies in all species involve certain risks to the mother and help to nurture the child, regardless of whether the child is wanted or not. There is just no scientific sense in which this could reasonably be called parasitism. This is a meaningless slur.

Does twinning suggest life doesn’t begin at fertilisation?

This is occasionally raised as an objection to the view that life begins at fertilisation. But the argument is rarely actually explained, and it is difficult to identify what the argument actually is.

Here is one version of the argument:

1. If X can split into two organisms, Y and Z, then X is not an individual organism.
2. Until a certain point after fertilisation, the blastocyst/embryo can split into two organisms.
3. Therefore, the blastocyst/embryo is not an individual organism.

The problem with this argument is that there is just no reason to believe that premise 1 is true. In fact, there is decisive reason to think it is false. There is a fairly obvious counter-example: pregnancy itself. In pregnancy, a woman ‘splits’ into two new organisms: the mother and child. But clearly this doesn’t mean that there was no individual organism before, and nor does it mean that the original organism disappears.

Another way of making this objection is to say that if the splitting of the original organism is relatively symmetrical, then the original organism disappears and two new organisms begin. This might be thought to be morally strange: it suggests that we have a moral reason to avoid twinning.

In response, first, there is some evidence that even at the two-cell stage, the organism is not symmetrical, and hence there is no clear reason to think that the original organism is destroyed. But suppose the original organism is destroyed: is this as morally counter-intuitive as we might think? As I explained under ‘How can killing an early embryo be seriously wrong?’, our moral intuitions on early embryology are likely highly unreliable, and given that twinning (and especially higher multiples) are significantly more dangerous for mothers, it does not seem counter-intuitive to say we should avoid twinning if possible – that it might be a pathological process (that happens to usually have perfectly happy results).

Perhaps there is a more robust argument from twinning, but I haven’t seen one: clearly an individual human organism can exist even if it then splits into two. So this does not impede the claim that an individual human organism is created at fertilisation.

Can men speak about abortion?

“Abortion shouldn’t even be debated”

Are there other arguments for the pro-life position?

“Don’t like abortion? Don’t have one”

Can men speak about abortion?

‘No uterus, no opinion!’ We have all heard this slogan. And before I respond, I do want to say that there is a grain of truth in it. Women’s voices and experiences have been marginalised, and women have too often had decisions made about their bodies by men, often in horrifying ways – whether through forced sterilisation programmes in the 20^th century, forced marriage in many cultures throughout history and the contemporary world, rape, including marital rape, and far more. These are grievous offences against the dignity of women, and it is right that we condemn them, allowing women to speak for and make decisions about themselves.

Likewise,  it is true that women have experiences which men cannot have, particularly relating to pregnancy, childbirth, motherhood, and the various challenges (including discrimination) that come with them. Women have unique experiential knowledge which deserves its own place in the debate.

Finally, it is also true that as a result of this asymmetry, men can be too quick to speak without seriously considering the implications of pregnancy, childbirth or motherhood for women. This can lead to insensitive, and sometimes even false, claims. And both can lead to bad policy. So humility is of considerable importance in debates relating to abortion, especially where it relates to hardships that women may go through.

But there are powerful reasons for men to speak about this topic, albeit with humility and caution. Many reasons, in fact, and I will just mention a few.

One of the most important is that there is a danger – in retrospect a very real one – that by making abortion a ‘women’s issue’ only, you create fertile ground for men to abandon women whom they have put in that position. By excluding men from the debate, you are also excluding them from their responsibility, effectively telling them: you may have sex with whomever you want, and if anything happens, it’s nothing to do with you. The man is thereby liberated from any accountability, leaving the woman alone to cope with the burdens of an unwanted pregnancy – whether she keeps it or aborts it. This is the ideal situation for male exploiters of women. It is not so ideal for the women left behind to pick up the pieces. Thus, telling men that pregnancy and abortion are nothing to do with them thereby enables men to have a mentality of abandonment and exploitation. It liberates them from any consequence of sex, in a way that could never be true for women. While some women may welcome this in given situations, the large share of women victimised by this mentality may not feel so liberated. The slogan takes a societal problem and places it entirely on the shoulders of women. Men should be part of the solution to unplanned pregnancy and abortion; excluding them only makes things worse.

A second problem is that this is ultimately a question about justice, and all of us have a responsibility to help redress injustice. A major theme in the contemporary social justice movement is that fighting for a vulnerable group while at the same time marginalising another vulnerable group is an eviscerated form of justice – in fact, it is another form of injustice. A second major theme is the idea of ‘allyship’ – that those in a position of power or privilege, rather than staying silent, should use that power or privilege to lift up and defend the vulnerable. Indeed, staying silent is seen as another mode of oppression. If these are on the right lines, then men have not only permission, but a responsibility, to speak about abortion as a matter of justice.

A third problem is that men are often asked to speak for women, either because they feel they do not have a voice or platform at all, or because they feel their voice or platform is in danger of marginalisation and having others say the same thing may empower them. This is presumably part of the motivation behind the He For She movement, which asks men to use their words and actions to advocate on behalf of women, amplifying their voices in the advancement of gender equality. For my own part, I can say that countless women have asked me to keep speaking about abortion, knowing that I can represent their voices to a wider audience than they have access to. It seems perverse to take away the megaphone those women have in the name of ‘giving them a voice’.

Fourth, there appears to be a problem of inconsistency. Pro-choice men are rarely, if ever, asked to stay out of the conversation – their views about the morality of abortion are perfectly well tolerated. More problematic still is the fact that all of us feel comfortable talking about issues which only affect a certain different demographic group. I was recently involved in two conversations with a large number of doctors about male circumcision and hymen repair surgery. Not one of the doctors of the opposite sex in either case expressed any hesitation about sharing their views on these topics, nor did any of the doctors of the relevant sex express any objection. Fortunately, when the topic occasionally moved onto female genital mutilation, both men and women were united in raising their voices in condemnation. I think this is a good thing – women should be able to speak about male circumcision, and men should be able to talk about – primarily to condemn – female genital mutilation and hymen repair surgery.

The problem here is that the objection simply makes no logical sense. You do not need to be able to be personally involved in a situation in order to have a moral opinion about it (though of course men are affected by abortion policy, since their taxes pay for abortions in many countries, if they are doctors, like me, they are at risk of losing their jobs for not being involved, and so on). I will never be President of the USA. But I certainly have views about how he or she should act. I will never be head of the Israeli or Palestinian armed forces. I certainly have views about how they should act. And so on. Possible examples are endless. The idea that people shouldn’t have opinions about situations they could never be in is demonstrably absurd. If someone cannot be in a position, that is a reason for humility and for listening. It is not a reason for silence or censorship.

Finally, if men cannot speak about abortion, it is hard or impossible to know where to draw the line – at what point is a man speaking about abortion? This issue came up a few years ago when I gave a talk on the moral status of foetuses, as I learned that a feminist society had planned to protest me. I assured my audience that I was not going to say anything about the legality of abortion, nor even the morality of abortion, but keep my talk strictly focused on the moral status of the foetus. The audience could draw conclusions on abortion themselves.

It’s clear that men should be able to speak about the moral status of foetuses. It would be absurd to suggest otherwise. But what if they conclude that foetuses are persons who should have legal protection? That still seems to be a claim primarily about foetuses, about which men are perfectly well permitted to opine. But yet it clearly has implications relating to abortion. Likewise, I have sometimes given talks on the mental health consequences of abortion, without making any claim about the morality or legality of abortion. Some have raised objections to this – but why? Are male doctors not allowed to talk about the psychiatric outcomes after a given procedure? Should male doctors not inform women about the risks of a surgical abortion? These implications are surely absurd. But if you say only that men shouldn’t give an opinion about whether abortion should be legal, the claim becomes so empty as to be pointless. If I can say that foetuses have an inalienable right to life, that the same legal protections should apply to them as any other human being, and so on, it seems that saying abortion should be illegal is hardly a big step further.

It is worth noting in closing that women are, in many countries, more pro-life, and more supportive of abortion restrictions, than men. So on balance, having fewer men in the conversation would only make the pro-life position appear more popular.

These are only a few of the reasons men should be permitted to speak about abortion. There are many more beyond the scope of this article which I hope to share soon.

“Abortion shouldn’t even be debated”

The idea that ‘human rights shouldn’t be up for debate’ is a tempting one. And of course, if you think abortion is a human right, you might be tempted to conclude that abortion shouldn’t be debated.

Of course, in some sense this is a circular argument – it assumes that abortion is a human right, which is exactly what is disputed. But there’s more we can say.

One of the problems with this view is that it seems too easy to avoid debate on any topic by simply asserting that your view involves upholding a human right. This will obviously not convince anyone who disagrees – and that is a major problem in a pluralistic society with significant disagreement about important issues.

Another problem is that debating even our most fundamental commitments can, in fact, strengthen them and put them on firmer grounding. It has long been argued that free speech and debate is, in fact, the best way to safeguard our most cherished values. Suppressing that debate only prevents people with the view from properly understanding their view and the basis for it – and that makes it far more fragile to cultural shifts in future.

JS Mill, in his seminal defence of free thought and speech, put it helpfully:

‘the peculiar evil of silencing the expression of an opinion is, that it is robbing the human race; posterity as well as the existing generation; those who dissent from the opinion, still more than those who hold it. If the opinion is right, they are deprived of the opportunity of exchanging error for truth: if wrong, they lose, what is almost as great a benefit, the clearer perception and livelier impression of truth, produced by its collision with error.’

What he is saying is that those who disagree with an opinion (say, the pro-life view) are equally – or more – deprived by the suppression of that view. This is because either the view is, surprisingly, correct, and pro-choicers are deprived of the opportunity to learn the truth. Or, the view is false – and discussing why the view is false helps to understand the truth – the truth’s ‘collision with error’ helps it to be more clearly perceived.

Understanding the truth better is helpful for at least two reasons: it safeguards that truth against cultural shifts, and it helps us come to the truth in what might be considered marginal cases.

Consider the killing of disabled children as an example. Most of us think that killing disabled children is horrendously wrong. But not all societies have thought so, and there is no guarantee no one in the future will think so. Perhaps in a few decades, there will be a cultural shift toward doing so, and a public debate on the topic. If so, what is more likely to protect the rights of disabled children – a society which just assumes without argument that killing disabled children, and is clueless in the face of counter-arguments, or a society which knows why killing disabled children is wrong, and can argue powerfully against it using reason and evidence? Plausibly, the latter.

Likewise, understanding why killing disabled children is wrong helps us to understand marginal cases where we might be unsure. Is it wrong to kill cows for food? Well, that depends on why killing is wrong – and hence we need to understand this topic, even if the conclusions are uncontroversial. If killing disabled children is wrong because ending sentient life is wrong, then killing cows for food is wrong for the same reason. But if killing disabled children is wrong because they are human beings made in the Image of God, then killing cows is not necessarily wrong – at least, not for that reason. So understanding the basis for uncontroversial, foundational ethical claims is important and helpful.

I think at the root of all this is an equivocation of ‘up for debate’. Of course, human rights should not be ‘up for debate’ in the sense that we should willingly give them up just if it is convenient, or if there is disagreement. But at the same time, for the reasons I’ve given, basic, foundational moral truths should be reflected on, and often the best way to do that is by debating them with thoughtful people who reject them.

It is difficult to claim that the truth of the pro-choice position is so obvious and foundational that it should not be debated – the large majority of the world rejects that position, and for prima facie comprehensible reasons. But even if it were an obvious, foundational truth, for the reasons I’ve suggested, debating it and reflecting on it would remain the best way to safeguard that truth, and should therefore be welcomed.

For more thoughts on this topic, see my contribution to Donald Downs’ and Chris Surprenant’s academic volume on academic freedom.

Are there other arguments for the pro-life position?

Yes. Some of them are different ways of approaching the same fundamental issue. Others are entirely different arguments entirely. Here are some examples:

Infanticide

1. Killing a newborn infant is wrong.
2. There is no morally relevant difference between a newborn infant and an embryo/foetus.
3. Therefore, killing an embryo/foetus is wrong.

This is clearly a powerful argument against late-term abortion – and is perhaps the reason most people already oppose late-term abortion.

Whether an argument against early or late-term abortion, the argument clearly needs some clarification. There are some morally relevant differences between newborn infants and human embryos – very early embryos are not sentient, for example, and are dependent on the mother. So when the argument says there are no morally relevant differences, what it means is that there are none which could make it wrong to kill infants but OK to kill embryos. Being dependent on another person is morally relevant – but it is not morally relevant in the sense that it makes it permissible to kill someone.

The argument relies on the fact that birth, in and of itself, does not fundamentally change the nature, and barely changes the abilities, of a baby. The baby clearly remains the same thing with substantially the same abilities before and after. Hence it primarily undermines the idea that abortion is permissible until birth, but becomes murder after birth.

It is worth noting that many of the foremost defenders of abortion in the academic literature agree with the second premise, at least the clarified version. It is widely – though not universally – agreed that if abortion is OK, so is infanticide (some also say that killing certain disabled adults is likewise permissible). The position that abortion is OK, but infanticide is not, is in fact a relatively uncommon one in the academic ethics literature. For those tempted to think that infanticide may be permissible, see ‘Is infanticide permissible?’

Since both of the premises are overwhelmingly likely, the conclusion is likewise probable.

Prenatal harm

1. It is wrong to harm foetuses by, for example, smoking, taking drugs, drinking excessively, and so on.
2. If it is wrong to harm foetuses in this way, it is wrong to kill them, which is a greater harm.
3. Therefore, it is wrong to kill foetuses.

These premises are plausible. Many people are committed to the first premise – at the very least, they would be against harming the foetus for trivial reasons, or intentionally. A serious reason would be needed for significantly harming the foetus in this way.

The second premise is extremely intuitive. Killing someone is, intuitively, a worse harm – or at least comparable – to giving them the kind of harm which results from smoking, for example. So it is difficult to see how harming them without killing them could be wrong, while killing them is permissible.

Harming the foetus must be wrong for some reason – presumably because the foetus has some substantial moral value. But if so, then wouldn’t killing it likewise be wrong?

It might be argued that harming the foetus is wrong not because it harms the foetus, but because it harms the child or adult which the foetus becomes. Killing doesn’t obviously harm the child or adult in the same way – it prevents them from existing. But on the leading account of why the embryo or foetus has limited moral value, something similar could be said for prenatal harm. Jeff McMahan of the University of Oxford argues that the reason foetuses are less valuable – and able to be killed – is because their future interests are made far less important by the fact there are few psychological connections between the foetus and the adult which it becomes. But if the psychological connections are so few as to make killing permissible, then those limited psychological connections likewise make harming the foetus more justifiable. If the adult is, for practical/ethical purposes, a ‘different person’ to the foetus, then harming the foetus harms the later adult only in the sense that it creates a ‘different person’ with a worse life, than the one who existed. But creating someone with a worse life than another possible person is clearly permissible, and is clearly not the same as making an existing person’s life far worse. Hence, on the foremost account of why killing a foetus is permissible, harming the foetus is plausibly likewise permissible.

Deprivation of a ‘future like ours’

1. Killing is wrong because it deprives an individual of a ‘future like ours’.
2. Abortion deprives an individual of a ‘future like ours’.
3. Therefore, abortion is wrong.

This argument, pioneered by philosopher Don Marquis, starts by considering why killing is wrong in the first place. This is a more difficult question than it might seem. If you ask a variety of people why killing humans is wrong, you will get a variety of different answers.

One reason that killing is wrong is because it deprives someone of a ‘future like ours’ – meaning, the kind of goods that mature humans typically enjoy – not only pleasurable experiences, but ‘higher’ goods like advanced cognition, marriage, education, and so on. It is intuitive that to kill me would be wrong in part because I would no longer be able to do these things.

Marquis suggests a few other reasons for why killing might be wrong, concluding that they don’t fully explain it. For example, killing can’t be wrong only because the victim wants to live – because some murder victims, perhaps with severe depression, do not want to live. Still, it would be wrong to kill them.

But if this is sufficient for killing to be wrong, then since most foetuses have such a future to look forward to – and indeed have more future than most humans – it follows that abortion is (usually) seriously wrong.

Prudential argument

1. If there is a reasonable chance that what you are killing is a person, it is wrong to kill without very strong justification.
2. There is a reasonable chance that foetuses are persons.
3. Therefore, abortion without very strong justification is wrong.

This is a simple practical argument best illustrated by analogy. Suppose you are hunting for food,* and you are not sure whether the creature in the distance is a bird or a child. It would be wrong to go ahead and shoot, even if the chance of it being a child is only, say, 10%. What this suggests is that it is not enough to think that foetuses are probably not persons – to justify ending their lives, you need to be really sure that they are not, at least in ordinary circumstances. Or, as Jack and Barbara Willke put it, ‘We do not bury those who are doubtfully dead. We would work frantically to help rescue entombed miners, a child lost in the mountains, or a person under a collapsed building. Does a hunter shoot until he knows that it is a deer and not another man?… the truly human thing would be to give life the benefit of the doubt.’

If, therefore, you are not sure whether foetuses are persons – you think they’re probably not, but you have significant doubts, and think you might be wrong – you should err on the side of caution and prevent them from being killed, at least in ordinary circumstances.

*Of course, many people think that killing animals is impermissible. But if killing animals is wrong because they have a right to life, this only appears to strengthen the pro-life argument, since foetuses are animals.

Religious arguments

For obvious reasons, these are a special class of argument. I decided that it would be better to tackle this topic more generally under the section ‘Abortion and religion’.

Impact on women and society

As I mentioned in ‘Why pro-life?’, pro-lifers have traditionally held that abortion is bad for both the child and her mother – and indeed for wider society. Although the trend differs slightly between countries, in many countries, women are more pro-life, and more supportive of abortion restrictions, than men.

Rather than repeat the same material on this issue at multiple points, I have summarised this argument under ‘How abortion harms women’, and included many different articles on the specific ways in which abortion is harmful for women and society. If those empirical observations are indeed genuine, they surely provide considerable reason to oppose widespread abortion, even if they do not in themselves make abortion inherently immoral. Societies would still have reason to make it an option of last resort, in order to best protect women.

“Don’t like abortion? Don’t have one”

Being pro-life is not about having a preference against abortion, or being personally averse to it. It is about believing that all human beings are equal and deserve equal protection from the rest of society. We oppose abortion because it violates the human rights of the most vulnerable humans in our world. To say this phrase is like saying, ‘Don’t like theft? Don’t steal’. If you’ve sincerely used this objection to the pro-life view in the past, ask yourself what is wrong with ‘Don’t like theft? Don’t steal’. When you answer that, you will probably see why it is an ineffective response to the pro-life position.

Opposition to euthanasia (or physician assisted suicide – I count these together in this article though they have important differences) can seem extremely counterintuitive at a very superficial level. We put dogs down when they suffer – why do we treat humans worse than dogs? Why do we cruelly force people to continue living when they desperately wish to die? In this short piece I will try to summarise the main reasons why people oppose euthanasia. There is much more that could be said – this is intended only to be a short piece summarising the main reasons.

Some reasons to oppose euthanasia are inherent moral reasons to oppose it: reasons to think euthanasia is inherently wrong. Other reasons are practical reasons which concede that even if euthanasia is not morally wrong in itself, legalising euthanasia would, on balance, be bad for a variety of reasons. It is helpful to be aware of this difference – you can think that euthanasia is not wrong while still opposing the legalisation of it for pragmatic reasons and the effect it would have on society more generally.

Arguments against euthanasia

So why should people oppose the legalisation of euthanasia? In no particular order:

1 Conscientious objection

It would likely be included as part of medical care with an expectation for healthcare professionals including doctors to actively participate or refer onwards[1], which would be a considerable conscience violation. Given that only ¼ of physicians would be prepared to participate themselves[2], this is a substantial concern.

2 The psychological impact on healthcare professionals

Performing euthanasia can take a considerable psychological toll on doctors, as the evidence from Holland and the US has shown[3].

3 The opposition of palliative care specialists

The overwhelming majority of palliative specialists in the UK oppose the legalisation of PAS[4]. These are the experts in end of life care and they overwhelmingly disagree that there is a need for euthanasia as opposed to good quality palliative care.

4 The disincentivisation of palliative care

Euthanasia/PAS disincentivise palliative care both societally and individually. Holland’s palliative care has been widely criticised[5], while the UK has been at the forefront of palliative advances precisely because we opted to develop palliative care. It is even common for patients in Holland to ask for euthanasia because of a fear of poor palliative care[6].

With the economic arguments in favour of euthanasia, it is extremely difficult to believe that economic considerations would not exert themselves with considerable force, even if they are not the initial motivation for legalising euthanasia/PAS. Ageing populations require vastly increased welfare expenditure[7], and the healthcare expenditure alone in the last year of life is disproportionately high[8].

Given that we already see hints of economic thinking in quality of life discussions at present, it is easy to see how those economic considerations would be transposed to deciding on whether to euthanise someone. As Baroness Warnock, one of the UK’s leading bioethicists in the last century, chillingly put it, ‘If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service… if somebody absolutely, desperately wants to die because they’re a burden to their family, or the state, then I think they too should be allowed to die… …there’s nothing wrong with feeling you ought to do so for the sake of others as well as yourself.’[9]

This has been seen on the individual level too. We have already seen cases of patients being refused treatment while being offered euthanasia instead, for reasons of cost[10] – several people in Oregon each year opt for PAS for financial reasons[11].

Palliative care is thereby disincentivised both in its development (why develop better palliative care if people are opting to die instead?) and in its implementation (it will be financially limited, and healthcare professionals will also be more inclined to learn about the easier way out rather than all the complex details of palliative care).

5 The increase in suicide rates

Legalising EPAS increases suicide rates more generally: Jones and Paton showed it is associated with a 6-12% increase in the total number of suicides, particularly affecting vulnerable groups such as women and the elderly[12]. The EPAS rates in Holland, Belgium, Oregon, etc., are far higher than the rate of people going abroad from the UK, and there appears to be very little evidence that a large number of people in the UK want to be euthanised – certainly nothing approaching the rates abroad[13].

6 Pressure on the vulnerable

This is part of a wider concern that legalising EPAS puts substantial pressure on vulnerable people to end their lives. Studies from Oregon have shown that since legalisation of PAS, the number of people undergoing PAS for the reason that they feel they are a burden to their family/friends has gone up dramatically, from 2 in the first year and 8 in the second year to 91 in 2018[14].

It is for this reason (among others) that Lord Sumption of the UK Supreme Court, when reviewing the evidence from other countries, found much evidence that this pressure existed, was significant, and was aggravated by negative attitudes to old age and disability[15].

There are people who are particularly vulnerable to a particularly malicious form of pressure: a majority of elder abuse is perpetrated by family members[16], and pressure on doctors from family members to euthanise their relatives is reasonably well documented[17]. It is difficult to work out safeguards preventing families (or others) from encouraging EPAS in the hope of financial gain.

7 The slippery slope

There are many reasons to suppose that a number of slippery slopes will eventuate: the slippery slope from PAS to euthanasia, from adults to children and infants, from voluntary to involuntary euthanasia, and from terminal physical illness to chronic and mental illness or even healthy patients. The reasons are:

• 1. That is exactly what has happened in other countries – despite the fact that these countries initially had very restrictive conditions and would have opposed the slippery slope from the start as well[18]. See below for the evidence from other countries.
  2. Slippery slopes are pretty standard when a major shift in bioethical thinking and policy occurs. Abortion is an excellent example – when abortion was legalised in 1967, it was with the sentiment that abortion was still wrong and a bad state of affairs – legalising it was just the lesser of two evils[19]. Abortion is now seen as entirely normal, and even a part of basic healthcare. When it was warned that the clause which allowed abortion up to birth for disability could also include minor ailments like cleft palate, Lord Steel himself said that this idea was ‘totally discreditable’, and Harriet Harman said that the legal scholars making the claim should be reported to the Law Society or Bar Council. Frank Doran MP called it ‘pure scaremongering’. We were told by Warnock and Steel that this clause existed only for children who were ‘incapable of living any meaningful life’. In fact, we now have several abortions for cleft palate under this clause each year, and many hundreds for Down Syndrome. We were told by Lord Brightman that the abortion of viable babies was unthinkable – ‘a doctor does not need an Act of Parliament to teach him that elementary duty [to try and deliver the child alive]’. He and Warnock claimed there was no need to mandate doctors to take ‘reasonable steps to secure that the child is born alive’[20]. In fact, now we have several hundred abortions for babies after 22 weeks every year (and hundreds more in the weeks leading up to 22 weeks)[21]. Doctors and other healthcare professionals were initially given substantial conscience protections. We now have burdens on doctors to refer patients for abortions against their conscience and even when there is no clinical indication[22], we have considerable pressure on healthcare professionals to actually perform abortions (become reality in other countries[23]), and we have imposed duties on healthcare professionals to be involved in facilitating abortions against their conscience as long as they are not actively participating in the operating room itself[24]. Finally, we had probably at most 10,000 abortions a year before abortion was legalised[25]. We now have over 200,000 a year in the UK[26].
  3. Once the gates have been opened to doctors killing their patients, it is difficult to see how economic pressures would not impose themselves. There are very powerful economic arguments for expanding the scope and practice of euthanasia once we allow it in some forms.
  4. More generally, the powerful reasons in favour of euthanasia are precisely why it is so dangerous – the fact that autonomy, compassion and economic arguments have so much power is precisely why a slippery slope is so plausible.
  5. The arguments for euthanasia themselves logically lead to considerable expansion. If autonomy is the driving motivation, then why should we impose any limits on euthanasia other than consent? If children or healthy adults or adults with eating disorders want to end their lives, who are we to get in the way of their autonomy? Likewise, if compassion is the driving motivation, it is difficult to see why we should impose any limits at all, even the requirement for a voluntary decision. As we will see below, these limits have been expanding in countries which have introduced EPAS, including extending EPAS to patients without their consent (sometimes with capacity, sometimes without)[27].
  6. A slippery slope is precisely what campaigners want – they have stated their ambition to introduce more widespread EPAS than initially proposed[28].
  7. Doctors are too under-resourced (especially in the UK) to do due diligence to the scope, level and quality of assessment needed to ensure that people meet the criteria for EPAS. There is simply no way doctors will be able to look at all the evidence that people are making the decision voluntarily, for example, even if doctors did have special training to ensure this. As an aside, those in Holland and other countries who have been tasked with this have spectacularly failed to ensure that patients meet the requirements before authorising their deaths – even when panels were set up who had the specific job of checking these cases[29]. Professor John Griffiths, perhaps the leading defender of Dutch euthanasia, commented that the results of the first two government surveys were, ‘as far as the effectiveness of control is concerned… pretty devastating.'[30] Professor Henk Leenen, described by The Lancet as ‘the guiding hand behind legislation in the Netherlands on euthanasia’, said as far back as 1990 that there was an ‘almost total lack of control on the administration of euthanasia’ in the country.[31]
  8. More generally, it is impossible to regulate the practice in these ways. The failings in other countries have been profound and have proven difficult to remedy (see below)[32].

8 The failure of euthanasia in other countries

The experience of other countries has been horrendous – even though these countries initially introduced EPAS in highly restrictive legal contexts. Take Holland, for example. In Holland, the 1995 review of euthanasia cases showed 135,500 deaths in the year, 3,200 of which were voluntary euthanasia, with another 400 PAS. In addition to this, there were 900 cases of involuntary and non-voluntary euthanasia, many of whom were competent patients who had not expressed a wish to die. These cases of what most of us in the UK would deem to be murder were treated with absolute impunity. In addition, there were 90 cases of euthanasia for newborn babies with disabilities (mainly spina bifida). There were also 14,200 cases of involuntary passive euthanasia – people killed by the withdrawal of treatment without their consent, with the intention of shortening the patient’s life[33]. These are huge numbers for such a small population and are profoundly worrying. Now euthanasia accounts for 4% of all deaths in Holland, but this proportion goes up hugely when including the more recent phenomenon of terminal sedation, where patients are sedated and then starved/dehydrated to death, often with the intention of shortening life. This alone accounts for 12-18% of all deaths in Holland, and has been devised to work around the few legal restrictions that do remain[34]. In Holland there are also now attempts to formally legalise euthanasia for those who are entirely healthy but simply ‘tired of life’[35]. There is already euthanasia for patients with depression and eating disorders[36]. Virtually every legal safeguard has been removed in the country over time. Remarkably, a top bioethicist defended the non-voluntary euthanasia in Holland (which he claimed constituted a substantial 40% of cases) by saying that it was voluntary because the family and doctors had chosen it – a bizarre inversion of the concept of voluntariness[37]. There are similar issues in other countries such as Belgium. In Belgium, for example, euthanasia without consent has been responsible for between 1.7-3.2% of all deaths, and even over 5% of all deaths in some regions[38], 50% of euthanasia nurses have been involved in cases where the patient did not consent[39], and 50% of all cases are entirely unreported[40]. Children of any age can be euthanised – this was even happening when it was illegal because of the cultural changes from legalising EPAS[41]. Organ donation from euthanasia in children is also permitted in both countries[42]. In Holland, euthanising newborn babies – usually because they have spina bifida – is reasonably common, to the number of around 100 each year[43].

Arguably, the most alarming part of all this is the lack of regulation and persistent illegal forms of euthanasia to which the state turns a blind eye. The examples are too many for this short post, but we have already seen that half of cases in Belgium are not even reported, despite the legal mandate. A particularly revealing example, though, is the case of Dutch GP, Dr van Oijen, who was one of the pitiful number people to actually be investigated for widespread illegal euthanasia, was actually convicted of murder, because he breached every single one of the key guidelines. There was no explicit request – in fact, the patient had declared that she did not want to die; there was not unbearable suffering (she was comatose at the time); there was no consultation with another physician; the drug had exceeded its expiration date after being left over from euthanising a previous patient; and he lied when reporting the death, saying it was by natural causes. Dr van Oijen was given a short suspended jail sentence, a suspended fine (because he lied on the report), and was given only a warning by the medical authorities[44].

Given breaches of regulations are so widespread (including lack of reporting, non-voluntary euthanasia, etc.), this is only the tip of the iceberg. But there are so few investigations for breaches in Holland (despite the known large number) that details of individual cases emerge only from time to time. There are far more details of the lack of regulation to be found in John Keown’s book (see references).

Indeed, the state of EPAS in Holland, Belgium and elsewhere, has filled volumes of books, and though I would like to repeat much of it here, I can only repeat a small bit. But it is worth closing this section with some comments from the United Nations Human Rights Committee – certainly no adamant pro-lifers:

“The Committee learnt with unease that under the present legal system more than 2,000 cases of euthanasia and assisted suicide (or a combination of both) were reported to the review committee in the year 2000 and that the review committee came to a negative assessment only in three cases. The large numbers involved raise doubts whether the present system is only being used in extreme cases in which all the substantive conditions are scrupulously maintained…

The Committee considers it difficult to reconcile a reasoned decision to terminate life with the evolving and maturing capacities of minors…

The Committee is gravely concerned at reports that newborn handicapped infants have had their lives ended by medical personnel. The State Party should scrupulously investigate any such allegations of violations of the right to life (article 6 of the Covenant), which fall outside the law…”[45]

This has not been assuaged. A more recent HRC report reiterated that ‘The Committee remains concerned at the extent of euthanasia and assisted suicides in the State Party’, noting that the lack of need for judicial review was a significant problem.

9 The inviolability of human rights

Our basic human rights are inviolable such that we are not even entitled to abdicate them ourselves. Take, for example, the right not to be enslaved, as enshrined in the ICCPR[46]. Most people are agreed that we do not have a right to sell ourselves into slavery as chattel slaves – to do so would be to degrade ourselves and disrespect our own humanity, as well as to set an unacceptable precedent for how human beings may permissibly be treated. Likewise, since the right to life is the most basic right, it is reasonable to suppose that we may not violate our own right to life.

10 The intrinsic value of life

Life has intrinsic value – this is the only way to explain human equality. Humans are equal regardless of their ‘quality of life’ or capacities, and most of us (for now – but not in Holland, etc.) are agreed that involuntary euthanasia on the grounds of disability is wrong. But if the value and dignity of our lives is not based on quality of life or capacities, then the ultimate value of human life must be intrinsic, not instrumental. If so, then it is hard to see how that value could be overridden by essentially disability considerations.

11 The inegalitarian infrastructure of euthanasia logic

This reflects the deeply inegalitarian intellectual infrastructure of the euthanasia advocacy movement. It is difficult to separate euthanasia advocacy from inegalitarian thinking. This is reflected most clearly in the history of the euthanasia movement: in the ancient world it was performed routinely on disabled and female infants, and when the movement renewed in the modern world it was primarily centred around the euthanising of mentally disabled people and other eugenic ideas. This is why it was such a central part of the Nazi movement – and was rejected soundly after World War 2 because of these links. For more on the history of the euthanasia movement, see my lecture here: https://www.youtube.com/watch?v=SGDAeF-UCcU&feature=emb_title

12 The inconsistency of moderate euthanasia laws and egalitarianism

Any ‘moderate’ euthanasia law that allows euthanasia in some cases but not others (as most advocates propose) will likely have the implication that some lives are worth less than others. But this is deeply inegalitarian. It will likely facilitate a cultural shift that will be reflected through our treatment of disabled people in other spheres of society.

In short, to sum up the last few points, our foundations for human equality and dignity are more deeply tied to notions of intrinsic value than we might have thought, and more fragile/accidental too.

13 The existential – not pain-filled – crises behind euthanasia

Surveys show that primary problems driving EPAS are existential – a lack of autonomy, dignity, etc[48]. These are not ultimately medical problems, but to give up on patients rather than trying to find solutions to these problems is not only not honouring our duties to vulnerable people suffering existential crises, but also to disincentivise the more general search for solutions for these widespread problems.

Arguments for euthanasia

To briefly respond to the arguments for euthanasia:

Autonomy

This is clearly a powerful argument for those of us living in a society which puts a premium on autonomy. But there are a number of concerns here:

• It is not frequently explained why autonomy has such a central position in our moral discourse, or what its value consists in. Certainly, it is difficult to see why it should be the foremost moral consideration above all others. And it is not obvious that the general liberal emphasis on autonomy over the last century or two has led to considerably happier or more flourishing societies – on the contrary, it seems to have contributed to a general lack of sense of meaning in life and life satisfaction in the West.
• There is a question about whether autonomy should override other values. If it does, then it is hard to see why euthanasia should be limited at all – any one, even healthy young children should be able to opt for it, or people with eating disorders, or people ‘tired of life’. If it does not, then the argument from ‘autonomy’ to legalising euthanasia is far from clear.
• Legalising euthanasia may (though this is far from clear too) facilitate the autonomy of some individuals opting for euthanasia, but it may at the same time limit the autonomy of many others. This is made much clearer by the aforementioned evidence that there is considerable pressure put on others to undergo EPAS once EPAS is legalised – and it seems like these numbers are far larger than the number of people whose autonomy might be facilitated by legalisation. And it certainly does not facilitate the autonomy of the many thousands of people who are involuntarily or non-voluntarily euthanised in jurisdictions which have liberalised EPAS laws.
• It is questionable whether legalising EPAS even facilitates the autonomy of those undergoing euthanasia, for the reasons described in the last point. It is a myth that legalisation is the only impediment to autonomy and that legalising something automatically gives someone a significantly freer choice whether or not to pursue it. We are simply subject to far too many and diverse pressures as humans for this to be plausible, especially in the case of euthanasia.
• We often limit autonomy, either to prevent harm to others (see point 3 in this section) or even to prevent indignity to oneself. There are many things we prohibit people from doing to themselves (and enlisting others to help) precisely because we think that they should not be allowed to harm themselves in such ways: for example, female genital mutilation, dwarf throwing for entertainment, slavery, elective limb amputation, duelling, driving without a seatbelt, and gay conversion therapy are all illegal (or thought should be illegal) even when consented to.
• Almost every euthanasia advocate does, in fact, put limits on autonomy in the case of euthanasia: as when they limit it to people who are terminally ill, or chronically ill, for example. So there is a tacit concession already that autonomy is not an overriding value.

Compassion

Again, it is immediately obvious why someone would intuit that allowing EPAS is the compassionate, and therefore the right, thing to do. This instinct is entirely natural and understandable. However:

• If EPAS is allowed on these grounds, it is again difficult to see how it should have any limits such as those described above. In particular, it is difficult to see why it should be limited to adults, or even to those who consent. This is, of course, why involuntary euthanasia of adults and children is so common in places like Holland.
• Not everything motivated by compassion is genuinely compassionate – 80-90% of foetuses diagnosed with Down Syndrome are aborted in the UK[49], often on the grounds that it is the compassionate thing to do. But studies suggest that 99% of people with Down Syndrome are happy with their lives[50], such that it is obviously not compassionate to end such people’s lives before their birth. Likewise, as with the previous examples (point 5 in the autonomy section), there are many things which may be compassionate to allow in the sense that someone may sincerely and desperately desire them, but which are not ultimately compassionate because they violate the basic respect due to human persons. In short, not all relieving of desperate desires is compassionate.
• Compassion is possible without helping someone to commit suicide. We normally accept this in the case of depressed or otherwise suicidal patients – we agree that the most compassionate thing to do is to do our very best to relieve them of their suffering without killing them.
• Most EPAS is not performed for reasons of pain[51] – as described before, the primary driving factors are existential. It is not compassionate to give up on the alleviation of these factors either individually or societally.
• It is not compassionate to allow EPAS for the many reasons I gave at the start of this post: it is not compassionate to disincentivise palliative care, to expose thousands of vulnerable people to unwanted pressure to end their lives, to advance the slippery slope of EPAS, to violate the most basic rights of human beings (even with their consent), to express the view in law that some lives are worth more than others and thereby dive into inegalitarian thinking, or to give up the principle of the intrinsic value of life. EPAS may certainly be motivated by good, compassionate intentions, and it may of course relieve some people of some very desperate feelings, but that does not suffice to render it the most compassionate policy option, all things considered.

Thanks very much to anyone who had the patience to read through all this. References are available on request, though I highly recommend John Keown’s Cambridge University Press book ‘Euthanasia, Ethics and Public Policy’ and John Wyatt’s ‘Right to Die?’ to anyone interested.

References

1. See GMC guidance on conscientious objection: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
2. See RCP poll, page 3. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
3. See Kenneth Stevens’ paper here: https://www.tandfonline.com/doi/abs/10.1080/20508549.2006.11877782
4. See RCP poll, page 2. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
5. See John Keown’s Cambridge University Press book ‘Euthanasia, Ethics and Public Policy: An Argument Against Legalisation’, 119-120.
6. Keown, 234-235.
7. See e.g. the brief parliamentary report at https://www.parliament.uk/business/publications/research/key-issues-for-the-new-parliament/value-for-money-in-public-services/the-ageing-population/.
8. See Aldrige and Kelley’s paper here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638261/
9. Warnock’s comments are available here: https://www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-Dementia-sufferers-may-have-a-duty-to-die.html
10. See, for example, the case of Barbara Wagner: https://abcnews.go.com/Health/story?id=5517492
11. See the official Oregon report: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year20.pdf
12. See Jones’ and Paton’s paper here: https://www.ncbi.nlm.nih.gov/pubmed/26437189
13. In 2014, those travelling to Switzerland from the UK numbered 126 (https://www.theguardian.com/society/2014/aug/20/one-in-five-visitors-swiss-suicide-clinics-britain-uk-germany), while many thousands are legalised every year in Holland and Belgium – despite vastly smaller populations.
14. All the data for Oregon is available at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx
15. See the Supreme Court judgment, page 83: https://www.supremecourt.uk/cases/docs/uksc-2013-0235-judgment.pdf
16. See the National Center on Elder Abuse’s summary here: https://ncea.acl.gov/What-We-Do/Research/Statistics-and-Data.aspx#perpetrators
17. Keown, 235.
18. See all of Keown’s book for  a lengthy, detailed exposition of the experiences in Holland, Belgium, the US, Canada, and Australia.
19. See the comments from David Steel here: https://www.theguardian.com/uk/2007/oct/24/politics.topstories3
20. See Finnis on all these claims: https://www.telegraph.co.uk/comment/personal-view/3599848/We-warned-them-they-mocked-us-now-weve-been-proved-right.html
21. See table 5: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/808560/2018_Abortion_Statistics_-_Data_tables__1_.ods
22. See GMC guidance again: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
23. See, for example, the recent case in the US: https://www.bbc.com/news/world-us-canada-49515372
24. See the recent Supreme Court case: https://www.supremecourt.uk/cases/docs/uksc-2013-0124-judgment.pdf
25. See the BMJ editorial: https://www.bmj.com/content/359/bmj.j5278
26. See table 1: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/808560/2018_Abortion_Statistics_-_Data_tables__1_.ods
27. See Keown’s book for great detail on this.
28. See, for example, Dying With Dignity Canada’s vision: ‘All Canadians have the right to choose their good death’: https://www.dyingwithdignity.ca/strategic_plan
29. See Keown, chapter 14 and passim.
30. Keown, 143.
31. Keown, 151.
32. Again, see Keown, passim.
33. See Keown, chapter 11 for all of these statistics
34. Keown, 188-193.
35. See, for example: https://www.ncbi.nlm.nih.gov/pubmed/29395542
36. See John Wyatt’s ‘Right to Die?’, 37-39.
37. See Robert Young’s SEP contribution: https://plato.stanford.edu/entries/euthanasia-voluntary
38. See Cohen-Almagor’s JME paper: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2614587
39. See Inghelbrecht et al.: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882450/
40. Cohen-Almagor, ibid.
41. See Raus: https://link.springer.com/article/10.1007%2Fs11673-016-9705-5
42. See Bollen et al.: https://adc.bmj.com/content/104/9/827
43. Keown, 138-139.
44. Keown, 163-164.
45. See the UNHRC report, page 78: http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=dtYoAzPhJ4NMy4Lu1TOebEPcGQ%2BYYGAQfcsLRzRFogZ74bJjVjU5%2B6UTfECS2iq5hzy3uM2EQhsQfT5sTAP9UuCzOa42RrEgD7trRpL98nMEmbGo%2FTZJpMPZRRApJzcB4MvhsQemKiGDZXAxmc3Ngg%3D%3D
46. See the UNHRC report, page 69: http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=dtYoAzPhJ4NMy4Lu1TOebFtU5BqeqKxX7regwxwKT5%2BLP6%2BVtuZTsZ5bmD4iSHPoUvgJYSKOEgGobXs9cXzHtj2gBlQb2hL6lwVIu%2B5N21MBPNQrXIXL%2FOS5XFXqBojQnGM40yDy%2FyJkjfd3CyE3DQ%3D%3D
47. See article 8: https://www.ohchr.org/Documents/ProfessionalInterest/ccpr.pdf
48. See, for example, the data for Oregon: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx
49. See: https://www.thejournal.ie/factcheck-babies-abortion-3823611-Feb2018/
50. See Skotko et al.: https://www.ncbi.nlm.nih.gov/pubmed/21910246
51. See, for example, the data for Oregon: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx

In the last week, the state of New York has passed a law liberalising abortion law in the state. The law allowed abortion, effectively, up to birth. After fierce political debate a few years ago, partial birth abortion – that is, killing the baby while half of it has already been delivered – was banned. But this was not easy: Bill Clinton vetoed the ban, the majority of Democrats voted against it, and 4 of the 9 Supreme Court judges voted against it. That is to say, the former President, nearly half of US legislators and nearly half of the top judges upholding justice in the country thought that it should be permissible to kill a baby while it is halfway out of the womb.

Fortunately, we are not in that place now. But we are close enough. The new law in New York allows abortion up until the moment before birth. Of course, many media outlets were quick to report harrowing stories of women in awful situations that no one would be wished to place in – where the woman’s life is at risk, for example. What they did not mention is that these women are being used as political pawns to push an absolutely radical abortion agenda that fights for abortion up until birth for any reason whatsoever.

Just how radical is this? Well, just 13% of Americans think that abortion should be legal in the third trimester (and only 28% think it should be legal in the second trimester. And it is not clear that they mean ‘on demand’ in these cases). Move to other countries in the West and the extremity of this viewpoint is made clear: only 1% of the UK population – for the most part more liberal than the US – think that abortion up to birth should be legal. For comparison, to see how extreme this is, remember that 5% of Brits don’t believe the Holocaust took place, 20% of Americans think that homosexuality should be illegal, while 40% of Americans believe in creationism. 5% admit to feeling negatively towards Jews and 24% towards Muslims. Third trimester abortion is far more extreme and outlandish than even these. It is utterly crazy. The only countries in the world that allow abortion on demand up to birth are North Korea, China, and Canada (and possibly Vietnam, though this is unclear). This is not flattering company. Remember that babies can survive from 22 weeks outside the womb. There is no denying – regardless of your views on early abortions – that third trimester abortion involves the killing of a real baby who could live outside the womb. But that is what New York has committed themselves to.

Can this really be the case? Many people are claiming that the law only intends to legalise third trimester abortion when the woman’s life is at risk. This is straightforwardly false. Begin by looking at the law. It allows abortion if ‘the patient is within twenty-four weeks from the commencement of pregnancy, or there is an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health.’ This sounds reasonable enough to those unfamiliar with health exceptions in Anglo-American law. But what the addition of ‘health’ – with no other qualifiers – achieves is abortion on demand. Why? In Anglo-American abortion law, ‘health’ is interpreted broadly, so that literally anything can count as a threat to mental health. In the UK, even sex-selective abortion – aborting a baby because it is a girl – is legal up to 24 weeks if a woman claims (or if a doctor, more familiar with the law, suggests to her, as is more usually the case) that having a baby girl would threaten her mental health. In American law, this has been explicitly enshrined in Supreme Court judgments: on the same day as Roe v. Wade in 1973, the Court also issued Doe v. Bolton, which clarified that ‘health’ is not just a ‘serious threat to physical health or life’, but ‘all factors – physical, emotional, psychological familial, and the woman’s age – relevant to the well-being of the patient.’ It does not matter, in the law, that abortion is probably causally associated with worse mental health, and drastically increases a woman’s mortality risk. In the law, abortion improves health by fiat alone.

If New York wanted a law that allowed abortion where the mother’s life is at risk, they could have said that. They added ‘health’, knowing the infinitely flexible legal understanding of that term. If they wanted a law that allowed abortion where there is a risk of grave injury to the mother, they could have formed a law like the UK’s, which says ‘grave permanent injury’. They said ‘health’. A happy term that surely no one could object to – until you realise that ‘health’ can mean literally anything – sex-selective abortion and all. This is abortion on demand up until the moment before birth.

Contrary to common opinion, abortion to save the life of a woman is exceedingly rare. Documentation is poor in the US, but in the UK we have good data for the reasons for abortion. Of nearly 200,000 abortions in the UK in 2017, 188 were performed to save the life of the mother or to prevent grave permanent injury (and not all of them were late term abortions). And yet there were at least 1,895 abortions performed past 22 weeks (the rough viability limit). This figure increases by many hundreds each week earlier. In the US, there are over 5,000 abortions performed past 21 weeks annually – and this is a significant underestimate as it does not include the data for California, Florida, Illinois, and a few other states, whose combined population is 80-90 million or so, and in largely very pro-choice states. It is simply not remotely plausible that these 5,000+ abortions are to prevent death or grave permanent injury.

Aside from the statistics, though, we know that late term abortions are performed for social reasons, because we have heard the same thing before. When partial birth abortion was debated, we were told time and time again that it was only in tragic circumstances, where the baby was unviable or the mother’s life is at risk. And yet abortionists later admitted that it was utterly false: that it was in the vast majority of cases performed on healthy mothers with healthy babies, after 20 weeks of pregnancy. “The abortion-rights folks know it, the anti-abortion folks know it, and so, probably, does everyone else.”

The abortion industry has lied to us about late abortions before. There is no reason to think that anything has changed. Late abortion has not become less common, nor less legal, nor has the abortion lobby changed. They are pushing for just as radical laws as before (see the support website for the New York law). They want abortion up to birth for any reason whatsoever, and in the New York Law, they have achieved it by transparent legal euphemism. And that is the cruel irony of the World Trade Center, whose memorial includes the names of unborn children killed in that cruel and vicious attack, celebrating the new law by lighting up with pink lights. The memorial below commemorates 11 unborn children whose lives were cruelly taken 18 years ago. The memorial above commemorates thousands more.

Update: Secular Pro Life has a number of blogs giving other reasons (including direct testimony from the doctors) to think that late abortions are not usually done for medical reasons. See here, here, here, and here.

What can we know about Jesus’ death, burial and resurrection without using any Christian sources?

It is sometimes alleged that all the sources for Jesus’ resurrection come from biased early Christians, and so cannot be trusted. I do not agree with this approach for a number of reasons: for one thing, that the early Christians were persecuted heavily for their faith suggests that they were not insincere propagandists but probably sincerely believed what they taught about Jesus, including that he was resurrected. And I (along with many New Testament scholars) think that there are other very good reasons to trust at least the basic gist of events as characterised in the New Testament, and particularly those relating to the last week of Jesus’ life. The wealth of independent sources for the crucifixion, for example, far exceeds almost any other event in ancient history, and is hard to explain simply by Christian bias. So let us not underestimate the strength of the historical evidence of Christian writers. The evidence I give here – from writers who not only denied Christianity but despised it – is a radical underestimate of the evidence in favour of Jesus’ identity and ministry.

But there is another reason this objection fails. It is that we can actually know a remarkable amount about Jesus’ final days without using any Christian sources at all. Some people will be familiar with some non-Christian sources for his life, perhaps in the form of the odd reference to his existence and perhaps his death. How much can they really tell us? Indeed, even Christian apologists tend to act as though non-Christian sources just tell us Jesus existed and was crucified, and not much more. So in preparation for a debate a couple of years ago, I made the game harder for myself. I determined to make a case for the resurrection using not a single Christian source. This does, of course, make things much harder. And as I noted at the start, it is not necessary for an honest, robust historical case for the resurrection. But when I took the task seriously, I surprised myself with the power of the case I ended up making. I want to relay some of that evidence here. Of course, I cannot hope to cover non-Christian corroboration of everything in the gospels – there are far too many relevant archaeological and literary finds to hope to cover in an article like this. And of course, much of this evidence supports the reliability of the Gospel authors, indirectly supporting the veracity of the resurrection narratives. But let me focus on more direct evidence for the resurrection in non-Christian sources and see how far we get. I will quote the passages fairly fully but embolden the relevant pieces – the reader may skip the rest of the quotes to save time if they wish.

Turn first to Tacitus, the Roman historian. In his Annals, which covers the history of Rome from 14-68 AD, he turns his attention in Book XV to the fire in Rome under Nero in 64 AD, for which Nero subsequently used Christians as scapegoats. He relates:

But neither human help, nor imperial munificence, nor all the modes of placating Heaven, could stifle scandal or dispel the belief that the fire had taken place by order. Therefore, to scotch the rumour, Nero substituted as culprits, and punished with the utmost refinements of cruelty, a class of men, loathed for their vices, whom the crowd styled Christians. Christus, the founder of the name, had undergone the death penalty in the reign of Tiberius, by sentence of the procurator Pontius Pilatus, and the pernicious superstition was checked for a moment, only to break out once more, not merely in Judaea, the home of the disease, but in the capital itself, where all things horrible or shameful in the world collect and find a vogue. First, then, the confessed members of the sect were arrested; next, on their disclosures, vast numbers were convicted, not so much on the count of arson as for hatred of the human race. And derision accompanied their end: they were covered with wild beasts’ skins and torn to death by dogs; or they were fastened on crosses, and, when daylight failed were burned to serve as lamps by night. Nero had offered his Gardens for the spectacle, and gave an exhibition in his Circus, mixing with the crowd in the habit of a charioteer, or mounted on his car. Hence, in spite of a guilt which had earned the most exemplary punishment, there arose a sentiment of pity, due to the impression that they were being sacrificed not for the welfare of the state but to the ferocity of a single man. (Book XV, 44)

The key points:

• Christians were persecuted very severely under Nero in 64 AD
• Christians were already disliked
• Their founder was known as ‘Christ’ (i.e. the Greek for ‘Messiah’)
• Christ had been executed in the reign of Tiberius (14-37 AD), sentenced by Pontius Pilate himself (Prefect/Procurator of Judaea from 26-36 AD)
• The movement stopped temporarily after his death
• The movement then restarted in Judaea
• It spread to Rome in large numbers

The Jewish writer Josephus, having defected to the Romans after being captured in the Jewish-Roman War, later put together Antiquities of the Jews, a history of the Jews from the beginning of the world through to the war. The work contains three central references to Jesus or his companions. And while the first of these is routinely discarded by lay sceptics as inauthentic, it is fair to say that the weight of scholarly opinion thinks there is an authentic core of the passage, even though scholars typically grant that there are Christian interpolations. The latter passages, of course, suffer from little to no such concerns regarding authenticity.

About this time there lived Jesus, a wise man, if indeed one ought to call him a man. For he was one who wrought surprising feats and was a teacher of such people as accept the truth gladly. He won over many Jews and many of the Greeks. He was the Messiah. When Pilate, upon hearing him accused by men of the highest standing amongst us, had condemned him to be crucified, those who had in the first place come to love him did not give up their affection for him. On the third day he appeared to them restored to life, for the prophets of God had prophesied these and countless other marvellous things about him. And the tribe of the Christians, so called after him, has still to this day not disappeared. (Book XVIII, 3.3)

Probably (though not certainly, since Jews had vastly differing concepts of Messiahs, and it is possible Josephus thought Jesus was a Messiah despite not being worthy of significant devotion) Josephus did not call Jesus ‘the Messiah’, although it is very plausible that he thought Jesus was held to be the Messiah by many people (in any case, his being titled ‘Christ’ early on is fairly uncontroversial). And he likely did not believe that Jesus had been resurrected. But he nevertheless otherwise confirms:

• Jesus was known as a wise man and the Messiah
• He performed ‘surprising feats’ and was a teacher
• He won over Jews and Gentiles
• On accusation by Jewish authorities, he was crucified under Pilate
• After this, he was still followed by a group who became known as ‘Christians’
• (Possibly), he was held to have been raised on the third day

Josephus shortly after goes on to describe the destruction of Herod Antipas’ army by Aretas IV and its interpretation as divine punishment for John the Baptist’s execution. He had previously just explained Antipas’ marital scandals:

But to some of the Jews the destruction of Herod’s army seemed to be divine vengeance, and certainly a just vengeance, for his treatment of John, surnamed the Baptist. For Herod had put him to death, though he was a good man and had exhorted the Jews to lead righteous lives, to practise justice towards their fellows and piety towards God, and so doing to join in baptism. In his view this was a necessary preliminary if baptism was to be acceptable to God. They must not employ it to gain pardon for whatever sins they committed, but as a consecration of the body implying that the soul was already thoroughly cleansed by right behaviour. When others too joined the crowds about him, because they were aroused to the highest degree by his sermons, Herod became alarmed. Eloquence that had so great an effect on mankind might lead to some form of sedition, for it looked as if they would be guided by John in everything that they did. Herod decided therefore that it would be much better to strike first and be rid of him before his work led to an uprising, than to wait for an upheaval, get involved in a difficult situation and see his mistake. Though John, because of Herod’s suspicions, was brought in chains to Machaerus, the stronghold that we have previously mentioned, and there put to death, yet the verdict of the Jews was that the destruction visited upon Herod’s army was a vindication of John, since God saw fit to inflict such a blow on Herod. (Book XVIII, 5.2)

While John the Baptist is not mentioned as connected to Jesus in this passage, virtually no scholar doubts the relation between them. So, making one tiny exception to my rule of using no Christian sources, we can assume that John the Baptist was an associate of Jesus. But then we learn a few more very interesting facts:

• John the Baptist was executed by Herod Antipas
• He was known as a good person who encouraged lives of righteousness and piety to Man and God
• He baptised fellow Jews and taught that righteousness was necessary for certain worship rituals to be acceptable to God
• He won crowds with charismatic preaching
• Herod Antipas, the Roman puppet governor of Galilee, was alarmed at John’s teaching and worried it would lead to sedition
• John the Baptist was relatively popular among the Jews

Finally, Josephus references James, the brother of Jesus, just subsequent to Festus’ death in 62 AD. He describes James’ execution by Herod Agrippa II:

Upon learning of the death of Festus, Caesar sent Albinus to Judaea as procurator. The king [Agrippa II] removed Joseph from the high priesthood, and bestowed the succession to this office upon the son of Ananus, who was likewise called Ananus. It is said that the elder Ananus was extremely fortunate. For he had five sons, all of whom, after he himself had previously enjoyed the office for a very long period, became high priests of God—a thing that had never happened to any other of our high priests. The younger Ananus, who, as we have said, had been appointed to the high priesthood, was rash in his temper and unusually daring. He followed the school of the Sadducees, who are indeed more heartless than any of the other Jews, as I have already explained, when they sit in judgement. Possessed of such a character, Ananus thought that he had a favourable opportunity because Festus was dead and Albinus was still on the way. And so he convened the judges of the Sanhedrin and brought before them a man named James, the brother of Jesus who was called the Christ, and certain others. He accused them of having transgressed the law and delivered them up to be stoned. Those of the inhabitants of the city who were considered the most fair-minded and who were strict in observance of the law were offended at this. They therefore secretly sent to King Agrippa urging him, for Ananus had not even been correct in his first step, to order him to desist from any further such actions. Certain of them even went to meet Albinus, who was on his way from Alexandria, and informed him that Ananus had no authority to convene the Sanhedrin without his consent. Convinced by these words, Albinus angrily wrote to Ananus threatening to take vengeance upon him. King Agrippa, because of Ananus’ action, deposed him from the high priesthood which he had held for three months and replaced him with Jesus the son of Damnaeus. (Book XX, 9.1)

They key point, of course, is that Ananus convened the Sanhedrin to put James, the brother of Jesus (known as the Messiah), to death.

Turn next to Pliny, governor of Bithynia (northern Turkey) in the reign of Trajan (98-117 AD). Pliny and Trajan shared many letters still extant, one of which concerns Pliny’s approach to Christians in Bithynia:

It is my custom to refer all my difficulties to you, Sir, for no one is better able to resolve my doubts and to inform my ignorance.

I have never been present at an examination of Christians. Consequently, I do not know the nature or the extent of the punishments usually meted out to them, nor the grounds for starting an investigation and how far it should be pressed. Nor am I at all sure whether any distinction should be made between them on the grounds of age, or if young people and adults should be treated alike; whether a pardon ought to be granted to anyone retracting his beliefs, or if he has once professed Christianity, he shall gain nothing by renouncing it; and whether it is the mere name of Christian which is punishable, even if innocent of crime, or rather the crimes associated with the name.

For the moment this is the line I have taken with all persons brought before me on the charge of being Christians. I have asked them in person if they are Christians, and if they admit it, I repeat the question a second and third time, with a warning of the punishment awaiting them. If they persist, I order them to be led away for execution; for, whatever the nature of their admission, I am convinced that their stubbornness and unshakeable obstinacy ought not to go unpunished. There have been others similarly fanatical who are Roman citizens. I have entered them on the list of persons to be sent to Rome for trial.

Now that I have begun to deal with this problem, as so often happens, the charges are becoming more widespread and increasing in variety. An anonymous pamphlet has been circulated which contains the names of a number of accused persons. Among these I considered that I should dismiss any who denied that they were or ever had been Christians when they had repeated after me a formula of invocation to the gods and had made offerings of wine and incense to your statue (which I had ordered to be brought into court for this purpose along with the images of the gods), and furthermore had reviled the name of Christ: none of which things, I understand, any genuine Christian can be induced to do.

Others, whose names were given to me by an informer, first admitted the charge and then denied it; they said that they had ceased to be Christians two or more years previously, and some of them even twenty years ago. They all did reverence to your statue and the images of the gods in the same way as the others, and reviled the name of Christ. They also declared that the sum total of their guilt or error amounted to no more than this: they had met regularly before dawn on a fixed day to chant verses alternately among themselves in honour of Christ as if to a god, and also to bind themselves by oath, not for any criminal purpose, but to abstain from theft, robbery and adultery, to commit no breach of trust and not to deny a deposit when called upon to restore it. After this ceremony it had been their custom to disperse and reassemble later to take food of an ordinary, harmless kind; but they had in fact given up this practice since my edict, issued on your instructions, which banned all political societies. This made me decide it was all the more necessary to extract the truth by torture from two slave-women, whom they call deaconesses. I found nothing but a degenerate sort of cult carried to extravagant lengths.

I have therefore postponed any further examination and hastened to consult you. The question seems to me to be worthy of your consideration, especially in view of the number of persons endangered; for a great many individuals of every age and class, both men and women, are being brought to trial, and this is likely to continue. It is not only the towns, but villages and rural districts too which are infected through contact with this wretched cult. I think though that it is still possible for it to be checked and directed to better ends, for there is no doubt that people have begun to throng the temples which had been almost entirely deserted for a long time; the sacred rites which had been allowed to lapse are being performed again, and flesh of sacrificial victims is on sale everywhere, though up till recently scarcely anyone could be found to buy it. It is easy to infer from this that a great many people could be reformed if they were given an opportunity to repent. (Letters, XCVII)

Pliny here confirms a number of details:

• Christians in Bithynia were punished severely
• There were certain crimes associated with Christianity
• Christians were stubborn in their beliefs and persisted to their execution
• Some were Roman citizens
• Christians were freed if they denied Christ and ritually worshiped the Roman gods and Emperor
• True Christians had a reputation for never doing any of these things
• Some Christians in Bithynia had ceased to be Christians 20 years previously – and so Christianity was likely in Bithynia at least 20 years previously
• Christians met on a fixed day before dawn to chant verses
• Christians worshiped Christ ‘as if to a god’
• Christians bound themselves to abstain from theft, robbery, adultery, and to commit to loyalty and financial integrity
• Christians reassembled later to take ‘ordinary, harmless’ food
• Christians, including women, were tortured
• The Church had ‘deaconesses’
• Christianity was seen as a degenerate, extreme cult
• Christianity had broad demographic appeal and extended into rural areas
• There was a desertion of temples, Roman cultic rites and animal sacrifice associated with the spread of Christianity

Trajan’s response is also extant:

Trajan to Pliny

You have followed the right course of procedure, my dear Pliny, in your examination of the cases of persons charged with being Christians, for it is impossible to lay down a general rule to a fixed formula. These people must not be hunted out; if they are brought before you and the charge against them is proved, they must be punished, but in the case of anyone who denies that he is a Christian, and makes it clear that he is not by offering prayers to our gods, he is to be pardoned as a result of his repentance however suspect his past conduct may be. But pamphlets circulated anonymously must play no part in any accusation. They create the worst sort of precedent and are quite out of keeping with the spirit of our age. (Letters, XCVII)

Trajan adds little new, but confirms that Christians were punished harshly, but spared if they denied Christ and worshiped the Roman pantheon.

Suetonius was a Roman historian most famous for his De Vita Caesarum – a set of biographies about the Julius Caesar and the Roman Emperors from Augustus to Domitian. He has two separate excerpts of note, the first of which is in his Claudius, regarding the Roman emperor reigning from 41-54 AD:

Since the Jews constantly made disturbances at the instigation of Chrestus, he expelled them from Rome. (Claudius, 25.4)

Although there is some debate regarding whether ‘Chrestus’ is a misspelling of ‘Christus’, the Latin word for Christ, most scholars agree that it is, according to which the well-known expulsion of the Jews from Rome under Claudius in 49 AD was particularly related to the new Jewish faction started by Jesus – Christianity. So we have here confirmation that Christians were of a sufficiently large number in Rome in 49 AD to warrant the expulsion of Jews from the city. This fits well with the other evidence we have so far considered.

But Suetonius also discussed Christianity in his biography of Nero, who reigned from 54-68 AD:

During his reign many abuses were severely punished and put down, and no fewer new laws were made: a limit was set to expenditures; the public banquets were confined to a distribution of food; the sale of any kind of cooked viands in the taverns was forbidden, with the exception of pulse and vegetables, whereas before every sort of dainty was exposed for sale. Punishment was inflicted on the Christians, a class of men given to a new and mischievous superstition. He put an end to the diversions of the chariot drivers, who from immunity of long standing claimed the right of ranging at large and amusing themselves by cheating and robbing the people. The pantomimic actors and their partisans were banished from the city. (Nero, 16.2)

Both passages from Suetonius mention Christians fairly incidentally, in lists of new policies instituted by the respective Emperors. But here Suetonius again confirms more clearly that Christians were severely punished under Nero, and that Christianity was a new phenomenon which was causing some sort of trouble.

A letter survives from Mara bar Serapion, a philosopher from Roman Syria, to his son Serapion. The dating is unclear, and stands sometime between 73 AD and the 3^rd century. Nevertheless, it seems to be another non-Christian reference to Jesus’ life:

What else can we say, when the wise are forcibly dragged off by tyrants, their wisdom is captured by insults, and their minds are oppressed and without defence? What advantage did the Athenians gain from murdering Socrates? Famine and plague came upon them as a punishment for their crime. What advantage did the men of Samos gain from burning Pythagoras? In a moment their land was covered with sand. What advantage did the Jews gain from executing their wise king? It was just after that their kingdom was abolished. God justly avenged these three wise men: the Athenians died of hunger; the Samians were overwhelmed by the sea and the Jews, desolate and driven from their own kingdom, live in complete dispersion. But Socrates is not dead, because of Plato; neither is Pythagoras, because of the statue of Juno; nor is the wise king, because of the ‘new law’ he laid down.

Mara bar Serapion hints at Jesus’ description as a ‘wise king’ – likely a reference to his status as Messiah among his followers – and the fact that his followers still existed following his law despite his execution.

Ending our discussion of Roman historians, let us look at Lucian, the satirist and historiographer who lived from 125-180 AD. His The Passing of Peregrinus recounts a pejorative biography of Peregrinus, a philosopher who he claims lived among Christians and exploited their generosity. While Lucian was a novelist, he also wrote works on historiography wherein he laid out stringent rules for historians recounting events of the past, and it is generally accepted that this work is broadly biographical rather than pure fabrication. But his clear antipathy towards Peregrinus lends us some scepticism towards the details. In any case, we need not be concerned with the reliability of the details of Peregrinus’ life in the account, since we are concerned with how Lucian portrays Christians here. He gives hints at various points:

It was then that he learned the wondrous lore of the Christians, by associating with their priests and scribes in Palestine. And—how else could it be?—in a trice he made them all look like children; for he was prophet, cult-leader, head of the synagogue, and everything, all by himself. He interpreted and explained some of their books and even composed many, and they revered him as a god, made use of him as a lawgiver, and set him down as a protector, next after that other, to be sure, whom they still worship, the man who was crucified in Palestine because he introduced this new cult into the world. (11)

Indeed, people came even from the cities in Asia, sent by the Christians at their common expense, to succour and defend and encourage the hero. They show incredible speed whenever any such public action is taken; for in no time they lavish their all. So it was then in the case of Peregrinus; much money came to him from them by reason of his imprisonment, and he procured not a little revenue from it. The poor wretches have convinced themselves, first and foremost, that they are going to be immortal and live for all time, in consequence of which they despise death and even willingly give themselves into custody, most of them. Furthermore, their first lawgiver persuaded them that they are all brothers of one another after they have transgressed once for all by denying the Greek gods and by worshipping that crucified sophist himself and living under his laws. Therefore they despise all things indiscriminately and consider them common property, receiving such doctrines traditionally without any definite evidence. So if any charlatan and trickster, able to profit by occasions, comes among them, he quickly acquires sudden wealth by imposing upon simple folk. (13)

In 16 he also goes on to mention that the Christians have food forbidden to them. So we learn from Lucian:

• Christianity was based in Palestine
• Christians were associated with synagogues/Judaism
• Christians worshiped a man crucified in Palestine who introduced the religion
• Christianity was prevalent in Asia (i.e. Turkey)
• They were extreme and generous
• They believed in an afterlife, and therefore do not resist punishment, including capital punishment
• They considered themselves brothers after abandoning Roman gods and worshiping the crucified man, whose way of life they followed
• They did not care much for material things and shared them as common property
• They had forbidden food

Turning briefly to non-Roman sources (except Josephus, whom we have already discussed), we move into slightly more controversial territory. A relatively late source (5-6^th century, though very likely based on much earlier tradition) the Babylonian Talmud. Of course, it is not sympathetic to Christianity, and notes:

It was taught: On the day before the Passover they hanged Jesus. A herald went before him for forty days [proclaiming]. “He will be stoned, because he practised magic and enticed Israel to go astray. Let anyone who knows anything in his favour come forward and plead for him.” But nothing was found in his favour, and they hanged him the day before Passover. (b. Sanhedrin 43a)

This confirms Jesus’ death at Passover, and his reputation for practising ‘magic’ and ‘leading Israel astray’.

Closer to the time of Jesus, we find that the Sanhedrin in the 80s AD formulated the following prayer:

For the renegades let there be no hope, and may the arrogant kingdom soon be rooted out in our days, and the Nazarenes and the minim perish as in a moment and be blotted out from the book of life and with the righteous may they not be inscribed. Blessed art thou, O Lord, who humblest the arrogant.

References to the ‘minim’ and the ‘Nazarenes’ in the Talmud normally refer to Christians, suggesting that we here have a very early reference to Jewish antipathy (and probably persecution) towards Christians in Judaea – and a confirmation that Jesus was held to be from Nazareth, i.e. a very small Galilean (and therefore maligned) town.

We turn finally to a marginal case: 7 examples of the Sator Square have been found in Pompeii, necessarily dating to before 79 AD. This set of letters – whose meaning is to scholars unclear – can be arranged into a cross shape spelling ‘Pater Noster’ (Our Father), with two As and two Os – ostensibly transliterations of Greek Alpha and Omega. If this interpretation of its unclear significance is correct it would confirm Christian presence in Italy at this stage. But the evidence is so unclear, and the evidence for Christian presence in Italy at this stage so strong in any case, that I will not use it henceforth.

Of course, this evidence can all be augmented enormously by uncontroversial details taken from the New Testament and other Christian literature, but part of my point here is to emphasise the strength of the case even on the (wildly implausible) assumption that Christian literature has nothing of value to tell us. The sources discussed here are those from within roughly 100 years of Jesus’ life. This is extremely impressive given the insignificance of Jesus’ life by secular Roman measures (bear in mind that the main sources for the Emperor Tiberius are broadly the same as the sources here), and given the ordinary nature of ancient sources for lives: the much larger time disparity between other ancient figures and their biographers is well known and does not need rehearsal here. So let us see what we have in total:

Jesus was from Nazareth, a small and maligned village in Galilee. He performed ‘surprising feats’ and ‘magic’ and was a respected teacher/wise man who won over Jews and Gentiles alike (Sanhedrin prayer, Talmud, Josephus). His movement was associated with John the Baptist, who was known as a good person who encouraged lives of righteousness, piety towards Man and God, who baptised fellow Jews, taught that righteousness was necessary for worship to be acceptable to God, and won crowds with charismatic preaching. John the Baptist was popular among the Jews and was executed by Herod Antipas, who was alarmed at his teaching and the possibility that it would lead to sedition. This may also have been related to Antipas’ marriage (Josephus).

Jesus himself was known as ‘Christ’ (i.e. the Greek for Messiah) (implied by ‘Christian’ in all authors, explicit in several), and as a ‘wise king’ (Mara bar Serapion). He started a new movement which was still associated with Judaism (Suetonius, Lucian).

He was executed (most authors) in the reign of Tiberius and sentenced by Pontius Pilate (26-36 AD) in Judaea (Tacitus, Josephus) at the request of the Jewish authorities (Tacitus, Josephus, Talmud, Mara bar Serapion), because he practised magic and led Israel astray (Talmud). This happened by crucifixion (Tacitus, Lucian, perhaps Talmud) and took place on Passover Eve (Talmud). The movement stopped temporarily after his death (Tacitus).

The movement then restarted in Judaea (Tacitus), perhaps related to a belief in Jesus’ resurrection on the ‘third day’ (Josephus). It persisted after his death (Tacitus, Josephus, Mara bar Serapion; implicit in all). It spread very quickly and in large numbers to Rome, northern Turkey, and perhaps other parts of Italy (Tacitus, Pliny, Lucian, Pompeii, Suetonius). They were present in sufficiently numbers and sufficiently devout to cause disturbances in Rome and Bithynia (Tacitus, Suetonius, Pliny) and empty temples and ruin the sacrificial market in Bithynia (Pliny). It had broad demographic appeal in age, class, gender and citizenship (Josephus, Pliny) and extended into cities and rural areas (Pliny).

The movement was widely reviled (most authors) and persecuted early on by Romans and Jews alike (Tacitus, Josephus, Pliny, Trajan, Suetonius, Lucian, Sanhedrin prayer), including torture of women (Pliny). They did not fear death and gave themselves over to capital punishment (Lucian). Reasons for this included being scapegoated, being widely reviled, simply being ‘Christian’, not worshiping the Roman gods and Emperor, stubbornness, transgression of the Jewish law, degeneracy, extremism, stirring up trouble, and perhaps depraved rituals related to food (very slightly later evidence confirms this as a charge of cannibalism) (Tacitus, Josephus, Pliny, Suetonius, Lucian). Jesus’ own brother, James, was executed by the Jewish authorities for having transgressed the law (Josephus). They were freed in Bithynia and probably elsewhere across the Roman Empire if they denied Christ and ritually worshiped the Roman gods and Emperor (Pliny, Trajan).

Finally, the movement was both associated with Judaism (Suetonius, Lucian; implicit in most authors) and yet reviled by it (Josephus, Sanhedrin prayer, Talmud). They worshiped Christ ‘as if to a god’ (Pliny, Lucian). They were stubborn in their beliefs until execution (Pliny, Lucian), known for their extremeness and generosity (Lucian), and had a reputation for never denying Christ or worshiping Roman gods (Pliny). They met on a ‘fixed day’ (apparently Sunday), chanted verses, bound themselves to abstain from theft, robbery, adultery, and to commit to loyalty and financial integrity (Pliny). They had a suspicious food-based ritual (Pliny). They believed in an afterlife and ‘despised death’, apparently not fearing it (Lucian). They considered themselves brothers and followed the way of the crucified Jesus (Lucian). They did not care much for material things and shared them as common property (Lucian). They had ‘deaconesses’ (i.e. ‘servants’ in the Church).

So we really know a rather impressive amount from non-Christian sources alone – much more than that Jesus was executed in the 1^st century AD! What we need to do now is explain the data. We know from Josephus (certainly from the interpolated version, and plausibly from the original version) that Christians believed in Jesus’ resurrection. In any case, it is not at all controversial that Christians believed in his resurrection at an early stage after his death. And this firm conviction explains almost everything we see after his death – the martyrdom, the despising of death, the persistence of the movement. Indeed, it would require something like this: a crucifixion victim was cursed according to Jewish law, and Messianic movements invariably died with the failure of the movement and the death of the Messiah figure.

So we have to ask what would cause belief in the resurrection. NT Wright’s work is most helpful here. He demonstrates ably the difficulty of explaining a belief in the resurrection in this case without appearances of the risen Jesus, and without an empty tomb. ‘Resurrection’ meant a bodily raising from the dead, and the Jews were well acquainted with grief hallucinations, visions, subjective feelings, and so on. They had terminology for those other than ‘resurrection’. And the idea of a resurrection before the end of the world was entirely anathema to Judaism. So it would take a radical experience to really convince Jews that someone – most especially a crucifixion victim from Galilee – had been raised from the dead. They would not have believed it if they did not see Jesus risen from the dead. And the movement would have died if Jesus’ tomb were not empty. That the holy day changed from Saturday to Sunday (implied by Pliny) fits the suggestion of Josephus that it was on the ‘third day’ that Christians held Jesus to have been raised. That it started in Judaea (not Galilee) after Jesus’ crucifixion there suggests this as the likely location.

This is not the place to go into detail on alternative explanations of these facts. But I do want to point, at least, to the non-Christian evidence for Jesus’ burial. It is often alleged that Jesus could easily have been not buried, or that his followers might have got the wrong tomb. I explain in a separate blog post (forthcoming) the non-Christian evidence for Jesus’ burial as a necessary part of Jewish practice, including for criminals. It is almost certain even without any Christian sources that Jesus was buried and that the location would have been known.

What was Jesus himself like? He was a Galilean who performed surprising feats, taught wisdom, and was linked with John the Baptist’s movement encouraging righteousness and authentic worship. This movement used baptism and was ended by Herod Antipas’ worry about sedition. He likely taught a stringent and radical moral code detailed above, which included extreme generosity and appeal to outcasts. He probably saw himself as the Messiah, perhaps as a sort of king (which lends itself most naturally to messianic interpretation), and may have instituted something like the Eucharist, perhaps near to Passover. He taught that his followers became brothers, and started a movement that soon worshiped him ‘as if to a god’ – perhaps implying stronger claims than we have made here. These claims very well explain his title as a ‘king’ and Antipas’ worry about sedition.

The question then arises as to the nature of Jesus’ kingdom. Messianic expectations were ordinarily (though not entirely) military, and his controversial execution as a politically unstable time must have required significant claims or trouble on his part, such as the charge of sedition. But in that case, why is there no hint of any military activity on the part of Christians? The natural interpretation is that he saw his kingdom as spiritual, not military. Of course, this is what we find in the gospels, but it is at least heavily implied by the secular writers.

We noted also that the new movement was heavily linked with Judaism and yet reviled by Jewish authorities. This fits perfectly with all we have said so far: Jesus was a messianic figure, but from many perspectives a failed one. And if he had made claims related to divinity, invited Gentiles and outcasts into his kingdom, and rejected the strict interpretation of the Sabbath for his believers, it is not difficult to see why he would be hated by the authorities.

What we end up with, therefore, is the same basic case made in normal arguments for the resurrection. I do not have space to make those arguments here, although they will be made as comprehensively as possible on my website in due course. But the fundamental question is how we explain the data here. Jesus was a remarkable figure, a unique man, who claimed to be the Messiah and perhaps made claims to divinity, who claimed to institute a spiritual kingdom on Earth, who taught a radical moral code and inspired a group of followers who spread across the world and persisted despite threat of death. After his crucifixion his tomb was empty and his followers (and others) had experiences of him risen from the dead.

All this evidence, of course, vindicates what the canonical gospels say about Jesus. So the evidence presented here in the first places gives us great reason to trust the gospels more than we might otherwise have done. But more acutely, the evidence here impresses upon us directly a picture of Jesus which itself needs explanation. And it is my considered judgment that the most complete, unifying explanation of these facts, given all the historical evidence, is that Jesus really was who he claimed to be. He was the long-awaited Messiah of Israel, who changed the world with his teaching and revealed the way to abundant life through following him and trusting in him. Through his healings and his death he ended the reign of corrupt humans and evil on Earth and instituted the reign of God himself. As a seal vindicating this ministry, God raised him from the dead, so that his followers, and we too, might despise death and be given to this new and mischievous superstition.

 

The tragic case of Savita Halappanavar’s death was inevitably going to be a major part of the Repeal the 8^th debate. According to Repeal the 8^th activists (and indeed many activists globally), Ireland’s abortion law forbade a termination in Savita’s case, leading to her death and thereby being responsible for it. The law should therefore be changed.

The above story is, however, false. This is demonstrably clear simply from reading the report on the case – written by a pro-choice advocate, Sir Sabaratnam Arulkumaran – although it does help to have a medical background, as I am privileged to enjoy in the United Kingdom. In this article I explain objectively why the above story is false, as well as correcting exaggerations made by some pro-life advocates on the same topic. Remaining as objective and focussed as possible, I do not seek to discuss any other issues relevant to Irish abortion law, polemics, medicine, or the like. I will not discuss relative maternal safety in Ireland, the ethics of abortion, or the character of the activists on either side. I do not intend by my terminology to imply that I agree with the standard medical terminology in this area. I use it only to be as clear as possible medically and legally.

The law as it stands

The most fundamental problem with the Repeal claims is identified clearly in Appendix A of Arulkumaran’s report: namely, that Irish law already gives legal protection to women and doctors seeking abortion in order to prevent a pregnant woman from death. Peter Finlay SC clearly lays out the legal basis for this in Constitutional, Statutory and Case Law, but since we are specifically addressing those in favour of repealing the relevant constitutional amendment, I note his key conclusions on the mother’s-life exception to the 8^th Amendment.

These stem primarily from Attorney General v X & Others (1992) (the 8^th Amendment was added in 1983). Finlay notes the relative clarity of the judges in this case, summed up by Chief Justice Finlay:

“I, therefore, conclude that the proper test to be applied is that if it is established as a matter of probability that there is a real and substantial risk to the life, as distinct from the health, of the mother, which can only be avoided by the termination of her pregnancy, such termination is permissible, having regard to the true interpretation of Article 40, s. 3, sub-s. 3 of the Constitution.”

In 1995 Chief Justice Hamilton gave a similar judgment:

“The Attorney General v. X. [1992] 1 I.R. 1 … established that having regard to the true interpretation of the Eighth Amendment, termination of the life of the unborn is permissible if it is established as a matter of probability that there is a real and substantial risk to the life, as distinct from the health, of the mother and that that risk can only be avoided by the termination of her pregnancy.”

Finlay concludes:

“As is evident from the foregoing, a termination of pregnancy which is likely to impact adversely upon the constitutional right to life of the unborn is nevertheless lawful under the terms of Article 40.3.3° if both of the two conditions are established as a matter of probability, namely (1) that “there is a real and substantial risk to the life, as opposed to the health, of the mother” and (2) that “that risk can only be avoided by the termination of her pregnancy.””

The matter is, therefore, relatively closed. Irish Law does not prohibit women from abortion where the life of the woman is endangered by continuing the pregnant. So if Savita’s life was endangered by continuing the pregnancy (as, I argue later, it was – though this is very rare), the decision not to terminate was not applying the law correctly. The law is sufficient as it stands. Savita’s tragic death is not a consequence of it, and so not a reason to change it.

It is nevertheless worth commenting on the medical facts to see what, exactly, should have been done, and why this tragedy occurred. Arulkumaran does this ably, comprehensively, and for the most part clearly (there is one key ambiguity, which I shall discuss).

Let us start with one key fact, probably the only fact in the case which could be used as support for the Repeal claims. Medically speaking, in order to treat Savita to give her the best chance of survival, the foetus should have been delivered earlier (almost certainly leading to its death, as the pregnancy was only 17 weeks advanced). Thus, claims such as the following:

“Abortion is not a cure for septicaemia (or any other medical condition)” (www.savitatruth.com/errors)

are misleading. Although it is open to debate whether delivery of the foetus in this case should be characterised as ‘abortion’ (since it was almost certainly going to die anyway), and although it is technically true that abortion never cures septicaemia (infection in the bloodstream, which usually originates from one particular part of the body), and that abortion is not in general a treatment for septicaemia, it is recommended in these cases that to improve the chance of the mother’s survival, the foetus should be delivered. I will briefly relay the story of what happened until this later stage (the report is much more detailed).

The history of the case

On 21^st October 2012 Savita came twice to the gynaecology ward with a history of severe back pain and a sensation of something ‘coming down’ in her pelvis. She was seen by the registrar whose assessment was that she was likely suffering an impending (and inevitable) miscarriage. On 22^nd October at 00:30 she suffered a spontaneous rupture of her membranes and vomited. From this point, Arulkumaran notes, she was at gradually increased risk of serious intrauterine infection (infection is a common cause of SROM, and given the vomiting and elevated white cell count the previous evening it is plausible that she already had the infection at this point – at the very least it should have been in the minds of the doctors – but we cannot guarantee that she had an infection at this point). She was also increasingly likely to deliver her non-viable foetus – and it was virtually certain that she would not retain the foetus until the point of viability (around 21 weeks at the very earliest). Later that day she had an increased heart rate, a sign of systemic infection. She was prescribed antibiotics, apparently only on the grounds that she had suffered rupture of membranes and so was at risk of developing an infection. The antibiotics were started over 24 hours after presentation. The plan was to await events (in the absence of known infection) and for 4 hourly observations. These observations did not occur this regularly – a central criticism made by the report.

Early in the morning of 23^rd October, Savita’s blood pressure was slightly low, another indication of possible infection. Shortly after, Savita and her husband were told that miscarriage was inevitable (though the foetus was still alive at this point). At this point, they also enquired about a termination. Then:

O&G Consultant 1 stated that the patient and her husband were advised of Irish law in relation to this. At interview the consultant stated “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart”. The consultant stated that if risk to the mother was to increase a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection “we can’t predict who is going to get an infection”.

The implication seems to be here that no suspicion of an infection had yet been made despite the markers (which, granted, at this stage were still relatively subtle and non-specific). Throughout the day, however, Savita’s heart rate gradually increased significantly further beyond normal bounds. Savita felt weak that evening. She was left to sleep by the time the doctor managed to see her that night.

At 4:15AM on 24^th October, Savita felt cold and shivery, an indicator of sepsis. She also vomited, confirming this. It was noted that the room was cold. She had a low grade temperature at 37.7C (i.e. slightly higher than normal, but not so clearly high as to indicate sepsis). No heart rate or blood pressure measurements were taken. At 6:30AM all observations were taken, the combination of which clearly demonstrated that Savita had (severe) sepsis – though with no indication yet of the origin of the infection. At the subsequent assessment at 7AM she exhibited tenderness in the lower abdomen, and had a ‘foul-smelling brownish discharge’ suggestive of intrauterine infection – this is important since intrauterine infections are treated very differently from other kinds of infections in the context. The diagnosis was given as likely chorioamnionitis. She was started on intravenous antibiotics and fluids. At the ward round she was diagnosed with chorioamnionitis by the consultant.

The aforementioned ambiguity lies here. Although a provisional diagnosis of chorioamnionitis was given, the consultant retrospectively confirmed to the investigation that the focus of the team was to find the source of the infection. Perhaps the most charitable way to interpret this is that they thought it was likely chorioamnionitis but still had some uncertainty. The report notes that they were explicitly awaiting a mid-stream urine sample result at this time – suggesting they were still looking for urinary tract infection as an alternative source. This is important, since RCOG guidelines say that delivery of the foetus during maternal instability (e.g. in severe sepsis) increases maternal and foetal mortality rates (and is thereby not recommended), unless the source of the infection is intrauterine (i.e. in chorioamnionitis). So if the infection were from somewhere else (e.g. her lungs), delivery of the foetus would harm both the patient and the foetus.

At this point, the consultant also retrospectively said that they did not think the patient was in septic shock (a late point in severe sepsis) because the blood pressure was OK. This was erroneous as the blood pressure was indeed low. The plan was to induce labour later in the day if the patient did not improve and if there was no foetal heartbeat present. The white cells came back shortly afterwards as very low – another sign of severe sepsis. The blood pressure by midday was low. The patient was shortly afterwards diagnosed with septic shock, likely (but still not certainly) to be secondary to chorioamnionitis.

At this stage, the infection was life-threatening, and the consultant discussed with another consultant the need for a delivery. A delivery in this context would have improved the chances of Savita surviving (though by no means made it overall likely), and if the foetus were viable, would likely have improved the chance of its survival too.  Sadly, it is virtually certain that the foetus would have died either way in this case.

Around this time, misoprostol was prescribed to induce delivery. It was not administered because Savita delivered the foetus spontaneously shortly afterwards. From this point Savita was transferred to a High Dependency Unit and then Intensive Care. Sadly, she passed away on 28^th October.

Many factors contributing (and some not contributing) to Savita’s death were identified by the investigation, including: difficulty of diagnosis of sepsis in mid-pregnancy; lack of clear local or national guidelines for management of early 2^nd trimester inevitable miscarriage; lack of use of Obstetric Early Warning Score Chart; delay in using empiric broad-spectrum antibiotics; lack of clear arrangements for following up blood test results; lack of attention paid to early markers of infection (e.g. raised white cell counts); lack of clear communication and handover; lack of expedition of delivery, failure to follow hospital guidelines on management of sepsis, and others. It is plainly evident to anyone studying the case that – even if Irish law is problematic in this respect – it would only be one part of a large chain of errors or failures of optimisation and so probably not the determinative factor. However, as we have seen, the law allows terminations in situations of such severity – the problem is that the clinical team did not appreciate the severity for a large variety of reasons.

Arulkumaran does note clearly that concern over the law influenced the clinical judgment of the team. It is not clear how or why this was the case, since they knew that the law allowed termination of the pregnancy in case of life-threatening emergency, and that sepsis secondary to intrauterine infection was a life-threatening emergency. Our best guess is that there was some residual uncertainty over the source of the infection making him doubt whether termination was appropriate. However, any such uncertainty about legality of termination was paralleled by uncertainty about the medical propriety of termination: as noted by the RCOG, delivery in the setting of maternal instability is not recommended unless the infection is intrauterine.

What appears to have happened in this case, then, is that there was a severely delayed recognition of the likelihood that Savita had an infection (signs of which were present very early on – infection is a common reason for spontaneous rupture of membranes and so should have been investigated straight away, and the blood tests later on the first day confirmed this), and of the likelihood of increasingly severe infection at each moment after membrane rupture occurred. There was also significantly delayed recognition of the probable cause of the sepsis as intrauterine. This meant that termination of the pregnancy was delayed and was a contributing (though by no means the causative) factor in Savita’s death.

So we are clear. Irish law permits termination of pregnancy in the case of risk to the life of the mother, and that is the situation Savita was in. The only thing to be said in favour of the Repeal claims in this case is that perhaps the law is misinterpreted by clinicians, or is ambiguous with respect to what level of risk is necessary. But clearly Savita had exceeded this level of risk far earlier than the clinical team thought – the issue is that the clinical team did not recognise the extremely high likelihood that the sepsis had an intrauterine source. These were errors of clinical judgment, with probably a small element of ambiguity over what level of risk constitutes a sufficient level. But what is clear that if Savita’s condition had been recognised appropriately in accordance with clinical standards and guidelines, termination would have legally been offered at an earlier stage. Even given the severity of her condition, however, and given the manifold clinical problems apart from a delayed offer of termination, it is far from clear whether she would have survived or not. My suspicion (though only an educated, informed clinical conjecture) is that she would not have. There were already too many delays on account of the clinical team failing to come to the right clinical diagnosis.

There is thus no reason to think that repealing the 8^th Amendment would prevent similar situations happening again, and no reason to think that the 8^th Amendment is to blame for this case. If there is any problem with the law (which I doubt, but that is not the topic of discussion), it is a problem of ambiguity, not a problem of substance. But that can be amended without repealing the law, since clearly the law already allows for termination when the mother’s life is at risk. I leave it to my readers to decide on the basis of other evidence whether or not the 8^th Amendment should be repealed: but this case is certainly no help to determining the answer.

M. Antonia Biggs et al. recently published a study on mental health and abortion showing (again) that there is negligible evidence that abortion improves mental health. In this case, it has mostly been spun in the context of undermining laws requiring physicians to explain the mental health risks of abortion to women considering one. I sent a letter to the editor of JAMA Psychiatry, where it was published, which was rejected. So instead of letting the effort go to waste I thought I might as well post it here:

A recent article in JAMA Psychiatry¹ argues, inter alia, that ‘there is no evidence to justify laws that require women seeking abortion to be forewarned about negative psychological responses.’ While the paper is a valuable contribution to the field, I must register dissent from this conclusion.

Firstly, despite the authors’ own study showing no significant difference in mental health outcomes between the relevant groups, the overall picture is more equivocal. Most pertinently, the authors introduce their study by way of a sweeping conclusion that ‘Studies finding a negative effect on women’s mental health owing to abortion have been critically refuted.’ But this is hardly the case, since some of the most widely acclaimed studies—those of Fergusson et al.^2-4—suggest precisely the opposite conclusion. The authors are surely cognisant of Fergusson’s work, yet there is not a single criticism of any of his studies in any of the references the authors here adduce (there is one brief, indirect allusion to the 2008 study, which nevertheless went unrefuted). Criticisms made almost entirely without reference to the best studies supporting the opposing view will not suffice. Moreover, they insist that their study improves on the methodological shortcomings of previous literature, omitting the facts that the specific flaws cited are addressed in Fergusson’s work, and that Fergusson offers both a more comprehensive treatment of confounding factors and a broader range of mental health disorders than do Biggs et al.

Secondly, supposing we grant the generalisability of their results, the normative conclusion still does not follow. The fact that overall rates of mental disorder may not increase after abortion does not entail that abortion does not cause mental disorder. It may be that it causes different kinds of mental disorder than does the continuation of pregnancy. The evidence does, in fact, suggest this to be the case—it is relatively uncontroversial that some psychological sequelae are abortion-specific.⁵ But then—just as women must weigh up the pros and cons of any other treatment using detailed relevant information, rather than simply being told that a treatment offers or does not offer ‘overall’ benefit—so they ought to be informed that abortion and continuation of pregnancy each confer their own separate mental health risks. This is consonant with and indeed supported by the authors’ claim that ‘women will vary in their responses to having an abortion or being denied an abortion’. The conclusion here is undermotivated.

References

1. Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study.JAMA Psychiatry. Published online December 14, 2016.
2. 2 Fergusson, DM, Horwood LJ, Boden JM. Abortion and mental health disorders: Evidence from a 30-year longitudinal study. Br J Psychiatry. 2008; 193(6):444-51.
3. Fergusson DM, Horwood LJ, Boden JM. Reactions to abortion and subsequent mental health. Br J Psychiatry. 2009; 195(5):420-6.
4. Fergusson, DM, Horwood LJ, Boden JM. Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Aust N Z J Psychiatry. 2013; 47(9):819-27.
5. Astbury-Ward E. Emotional and psychological impact of abortion: a critique of the literature. J Fam Plann Reprod Health Care. 2008; 34(3):181–4.

A few people have been asking for the essay I recently won a university prize for, so here it is. It’s a brief but very technical piece on whether foetuses have the right to life. I’m currently turning it into a much more comprehensive piece. Enjoy.

Does the foetus have a right to life?

After my recent post making a brief case for the pro-life position, it occurred to me that, in addition to the secular case I made there, Christians have extra reason to hold to the pro-life position. Here, I hope to give another unsatisfactorily brief overview of some extra motivations for Christians to promote the life of the unborn.

I express my indebtedness to David Albert Jones’ “The Soul of the Embryo” for much of what follows. Jones’ work is an exceptionally thorough and insightful work on the history of Christian attitudes towards abortion, complete with insight into the various contexts in which Christians have spoken. I would recommend to the book to any Christian seeking to learn more about the topic.

Christianity, personhood and the image of God

According to Christian tradition (and ultimately, according to the Bible), human beings are made in the image of God. What, exactly, this means is hard to say, but it means we should be wary of any account which tries to derive humans’ moral worth from “personhood”, or from the criteria which people often claim constitute personhood. In the Bible, it is wrong for humans to rob each other of their lives and thereby their dignity, even when modern “personhood” criteria are not present. The Bible does not say that humans have dignity only insofar as they are conscious, mentally rich, physically capable or economically independent. This would exclude the disabled, the foolish, the sick, the young and the poor. But these are precisely the kinds of people the Bible commands us to especially look out for, and this concern for all human life, even those at the very bottom of society, is one of the things that makes Christian teaching so unique and profound. There are countless passages in the Bible where Christians are commanded to take special care of “the least of these”, and this includes all the people who are excluded by many contemporary “personhood” analyses.

Where does human worth come from? One of the foremost claims in the Bible about humans is that they are made in the image of God. John Wyatt helpfully elaborates on some of what this means. It means that we are dependent on him, and that our value comes from him. It means that we are fundamentally relational, and that there are no such things as isolated, autonomous individuals. It means that we are valuable and treasured not because of what we do, but because of what we are. Finally, it means that human beings are all equal in the eyes of God.

What does this imply for the abortion debate? It means that there are real problems with any view that tries to ground human dignity, worth and rights in anything like merit or ability, mental capacity or independence. For Christianity, humans are not treasured because of their achievements or abilities, but because they are created in the image of God – and this is just as true of those who are mentally ill or physically incapable. Nor are humans treasured because they are independent – they depend fully on God, and even Jesus became incarnate to depend on fellow humans. The kinds of people excluded by typical personhood criteria like these are exactly the kinds of people God commands particular care for: “For the LORD your God is God of gods and Lord of lords, the great God, mighty and awesome, who shows no partiality and accepts no bribes. He defends the cause of the fatherless and the widow, and loves the alien, giving him food and clothing. And you are to love those who are aliens, for you yourselves were aliens in Egypt.” (Deuteronomy 10:17-19)

So we cannot get away with saying that human beings are not valuable until they meet some other criteria: all humans are equal in God’s eyes, and they do not rely on their abilities or independence for their worth. Christians are called to care for the vulnerable, and to look out for the last, the least and the lost. And they are called to recognise the worth, dignity and rights of all human beings just as God does.

Christian tradition and the unborn

All of this provides good reason to think that the unborn, being human beings, are just as entitled to life as the rest of us (perhaps even more so, given their plausible innocence). The Bible says nothing about less developed human beings being less valuable – indeed, children are given a very special role throughout the Bible, and especially by Jesus himself.

But before turning to some of the more explicit Biblical teaching on the unborn, I’d like to briefly explore historical Christian teaching on the subject. Until the mid-20^th century, the Church has been unanimous in affirming that the unborn have been part of the human family. There has been some disagreement regarding when, exactly, the unborn became ‘ensouled’, but even the view that the unborn were not ensouled at conception took centuries to develop in contradiction to the earliest Church teaching, and even then the unborn child was held to be ensouled at a relatively early stage.

So what have Christians said throughout the centuries? One important contextual factor to recognise is the culture Christianity grew up in. In my first post, one of my arguments depended on the lack of a morally significant difference between the unborn and newborns. This point is conceded by the foremost pro-abortion ethicists (e.g. Singer, Tooley), and interestingly, it seemed to be held to some extent by pagans during the early periods of Christianity. Sex-selective infanticide was common in the Greco-Roman world, and the rights of a father included the right to kill his newborn son or daughter (the terminology of ‘discarding’ newborn girls, similar to today’s terminology of ‘terminating’ pregnancies, should be noted). Cicero claimed that the basis of Roman law included the judgment that “deformed infants shall be killed.” Seneca claimed that it was customary to drown newborns who were weakly and abnormal. Aristotle and Plato recommended the killing of disabled infants. And so on.

In opposition to this, the early Church was firmly against abortion and infanticide. Their opposition to abortion cannot, therefore, be put down to contextual factors: that they were influenced by the cultures around them, for example. Rather, this came straight out of their faith. The Didache, a work written as early as some of the New Testament writings, states, “You shall not kill a child by abortion nor kill it after it is born.” The Letter of Barnabas, written shortly after, makes the same statement. Athenagoras, writing in the 2^nd century, claimed that “those women who use drugs to bring about an abortion commit murder.” Similarly, Tertullian wrote that “for us murder is once for all forbidden; so it is not lawful for us to destroy even the child in the womb”. John Chrysostom wrote that abortion was even worse than murder, because it turned the womb into “a chamber for murder”. More examples of early Christian writers expressing the same sentiments can easily be adduced, and include Minucius Felix, Lactantius, Clement of Alexandria, Ambrose, Jerome, Cyprian and Hippolytus.

These writings cannot be dismissed as the extremist meanderings of morally dubious characters. These people were coming out of the earliest tradition in the Church founded by Jesus himself, and it was precisely these beliefs about human value and equality which led them to oppose the widespread infanticide in their culture. Probably, too, it was the influence of these Christians which led to infanticide eventually being outlawed in the Roman Empire.

It is, of course, worth also mentioning the view of the Church Fathers on the stage at which they thought a new human being was formed. After all, it is possible that they were only against abortion after a particular point in pregnancy. As it happens, the earliest Church traditions said that ensoulment took place at conception. Clement of Alexandria, Gregory of Nyssa and Tertullian all held to this view. Tertullian defended it on the basis that the soul is generated by the parents, and the most natural conclusion is that conception is therefore the beginning of a new soul. This fits neatly with our belief that our parents really did create us and that we really were conceived. It also fits neatly with a Biblical understanding of procreation. It wasn’t until the 4^th century that the suggestion that ensoulment didn’t occur until slightly later was even raised, and even then, abortion was still held to be a serious sin before ensoulment.

This opposition to abortion and infanticide has been characteristic of Christians until the mid-20^th century, in all strands of Christian tradition. It was the basis for the outlawing of infanticide, and the basis for the particularly Christian ministry of looking after orphans and the abandoned – when Christians first began this work, there were even stories of pagans abandoning their babies on the doorsteps of Christians, because they knew they would be looked after. If we are going to break with this tradition, there better be exceptional reason to do so.

The Bible and the unborn

More importantly, of course, is what the Bible teaches about the unborn. And here, too, there is good reason to think that the Bible recognises the value of the unborn. I have already discussed the Biblical view towards humans a whole, and in particular towards the equality of human beings. If the unborn are members of the family, it follows that the Biblical position is that abortion is as serious an issue as murder, as the earliest Christians taught.

There is good Biblical reason to view the unborn as being part of the human family. Psalm 139 speaks of God seeing the Psalmist’s “unformed substance”, and knitting him together in the womb. The Psalmist is “fearfully and wonderfully made” – an image at complete odds with the parasitic blob of cells the embryo is often described as. Ecclesiastes 11:5 speaks of breath coming to the bones in the womb, an image reminiscent of the breath of life given in Genesis. Isaiah and Jeremiah speak of being called and named while in the womb, and there are many other examples of Biblical figures in the womb: Job, Jacob, Esau, Samson, Samuel and John the Baptist, to name a few (the Maccabeean revolters, to name some more, for Catholics). Luke uses the same Greek word for the unborn John as for the newborn Jesus, and as for children appearing later in the gospel. Furthermore, many of these passages explicitly label conception as the starting point for human life.

Most obviously, Jesus himself was spoken about in the womb, after Mary conceived. Christians have never believed that Gabriel announced to Mary that she conceived a parasitic blob of cells with no worth until he was born. Gabriel announced that Mary had conceived Jesus the Messiah himself! And Jesus has always been held, throughout Christian history, to have been conceived, unsurprisingly, at conception. The Biblical evidence and Christian tradition for this is so strong that even those writers (e.g. Aquinas) who thought that ensoulment happened some time after conception thought that Jesus was an exception to this rule. But if Jesus took on our humanity and was made like us in every way, why should we be any different? This seems like a very compelling reason to think that humans begin to exist at conception, as a result of their parents’ procreative act.

Summary

In summary, there are overwhelming reasons for Christians to endorse the pro-life position. Christians are called to be champions of the weak and vulnerable, and to recognise the dignity and equality of all members of the human family. The most dangerous place for most human beings is in the womb, and this is even more true for women and ethnic minorities. Christians have an extra duty to carry on their tradition of caring for the particularly young and vulnerable. Moreover, in addition to the reasoning I gave in my first post, Christians have extra reason to think that human life begins at conception, and they have an overwhelming historical tradition of standing up for life in the womb.

Lord, help us to celebrate the life You give in all its forms
Help us to stand up for life and care for the vulnerable, born and unborn
Sorry for when our condemnation pressurises women into hiding their pregnancies
And help us to support and uplift those making these decision
Most importantly, help us to find healing in You
And to know that in You, there is no condemnation
In Jesus’ name, Amen

The early Church on killing and capital punishment

I’ve recently been asked a fair bit about my sympathies with pacifism, and especially about my opposition to capital punishment. One part of these dialogues has been looking at the tradition of the early Church which, I believe, was unanimously against killing, a tradition so strong that I hold it to be of comparable strength with almost any Christian doctrine. While I do not currently have time to lay out a complete case against killing, I would like to offer a brief discussion of the early Church’s view on it. What follows is pretty much entirely a distillation of Preston Sprinkle’s treatment of the subject in his book Fight: A Christian Case for Nonviolence, a sincere and compelling book I fully recommend.

The first important point is the widespread and early agreement on this issue. If the early Church was divided on the issue, it would not carry so much weight. But the unanimity, even among geographically distant parts of the Church, gives their opinion considerable weight. Sprinkle puts it like this: “Leaders from North Africa, Egypt, Israel, Asia Minor, and Rome. They all agree. Christians should never kill. Not in self-defense. Not as capital punishment for the guilty. Not in a just war. Never.”

What did early Christians say about killing? Here is a sample:

“We who formerly used to murder one another do not only now refrain from making war upon our enemies, but also, that we may not lie nor deceive our examiners, willingly die confessing Christ.” Justin Martyr (Apology, 1:39)

“Neither Celsus nor they who think with him are able to point out any act on the part of Christians which savours of rebellion. And yet, if a revolt had led to the formation of the Christian commonwealth… the Christian lawgiver would not have altogether forbidden the putting of men to death; and yet He nowhere teaches that it is right for His own disciples to offer violence to anyone, however wicked. For He did not deem it in keeping with such laws as His, which were derived from a divine source, to allow the killing of any individual whatever. Nor would the Christians, had they owed their origin to a rebellion, have adopted laws of so exceedingly mild a character as not to allow them, when it was their fate to be slain as sheep, on any occasion to resist their persecutors.” Origen (Against Celsus, 3:7)

“By this very fact they are invincible, that they do not fear death; that they do not in turn assail their assailants, since it is not lawful for the innocent even to kill the guilty” Cyprian (Letter 56)

“What man of sound mind, therefore, will affirm, while such is our character, that we are murderers? … For when they know that we cannot endure even to see a man put to death, though justly; who of them can accuse us of murder or cannibalism? … But we, deeming that to see a man put to death is much the same as killing him, have abjured such spectacles. How, then, when we do not even look on, lest we should contract guilt and pollution, can we put people to death?” Athenagoras (Plea for the Christians, 35)

“Has the Creator, withal, provided these things for man’s destruction? Nay, He puts His interdict on every sort of man-killing” Tertullian (De Spectaculis, 2)

“For he who reckons it a pleasure, that a man, though justly condemned, should be slain in his sight, pollutes his conscience as much as if he should become a spectator and a sharer of a homicide which is secretly committed … Therefore they do not spare even the innocent, but practice upon all that which they have learned in the slaughter of the wicked. It is not therefore befitting that those who strive to keep to the path of justice should be companions and sharers in this public homicide. For when God forbids us to kill, He not only prohibits us from open violence, which is not even allowed by the public laws, but He warns us against the commission of those things which are esteemed lawful among men. Thus it will be neither lawful for a just man to engage in warfare, since his warfare is justice itself, not to accuse anyone of a capital charge, because it makes no difference whether you put a man to death by word, or rather by the sword, since it is the act of putting to death itself which is prohibited. Therefore, with regard to this precept of God, there ought to be no exception at all; but that it is always unlawful to put to death a man, whom God willed to be a sacred animal.” Lactantius (Divine Institutes, 6:20)

“For since we, a numerous band of men as we are, have learned from His teaching and His laws that evil ought not to be requited with evil, that it is better to suffer wrong than to inflict it, that we should rather shed our own blood than stain our hands and our conscience with that of another” Arnobius (Against the Heathen, 1:6)

Sprinkle goes on to discuss Christians in the military, his main thesis being that Christians unanimously rejected the permissibility of Christians killing in the military. Even when Christians believed in just war, Sprinkle adds, they still thought that Christians should not kill in the military.

Sprinkle first points to Tertullian, who wrote a whole treatise forbidding military service among Christians (De Corona), and who wrote elsewhere that “the Lord afterward, in disarming Peter, disarmed every soldier”. Tertullian even takes it for granted that sacrifices and capital punishments are so obviously wrong as to be virtually non-negotiable: “But now inquiry is made about this point, whether a believer may turn himself unto military service, and whether the military may be admitted unto the faith, even the rank and file, or each inferior grade, to whom there is no necessity for taking part in sacrifices or capital punishments.”

He then mentions Origen who, despite recognising the necessity and inevitability of war in some contexts, in those same contexts forbade Christians killing on the grounds of the gospel being a doctrine of peace. Sprinkle also refers to an anonymous document often attributed to Hippolytus, which is more explicit: “A military man in authority must not execute men. If he is ordered, he must not carry it out. Nor must he take military oath … the catechumen or faithful who wants to become a soldier is to be rejected, for he has despised God.” (Apostolic Tradition, 16)

Of course, there are familiar examples of Christians in the military, both in the New Testament itself and in early Church literature.  But Sprinkle makes several points in response:

Firstly, this clearly does not constitute an endorsement of the profession. Richard Hays is quoted on this point: “their military background is no more commended by these stories than are the occupations of other converts, such as tax collectors and prostitutes”.

Secondly, the point of the stories is not to show that military service is compatible with the gospel: after all, those in the military were essentially forced to take part in idolatrous practices, and yet these are not addressed in the narratives. Rather, the point of these stories is to show the powerful, universal attraction of the gospel.

Third, after the New Testament, we have no record of Christians in the military until 173 AD, over a century later!

Fourth, those same Christian writers who mentioned Christians in the military tended to be the ones explicitly prohibiting it – so the fact that Christians were in the military is clearly compatible with Christians, on the whole, thinking that it was impermissible! Sprinkle notes that clearly not all Christians thought that joining the military was impermissible, but that all the theologians did, and that Christians have always engaged in activities out of line with Church teaching – after all, 30% of Mennonite men participated in World War II!

Fifth, we don’t know much about what relationship the role in the military had to conversion. That is, we don’t know if Christians were already in the military prior to conversion (as in the New Testament), and we don’t know what Christians in the military did about their jobs after conversion. Nor do we know to what extent those Christians in the military felt ambivalent about their two vocations.

Sixth, and perhaps most importantly, many (maybe even most) jobs in the military did not require killing. Many amounted to office jobs, and the military had far more to do than simply fight: firefighting, mail delivery, accounting, messenger services, general administration, custody of prisoners, public transport, road maintenance and other civil functions constituted the bulk of military work, according to Daniel Bell Jr. This would explain those early Church writings which allowed Christians to join the military, while forbidding them from killing in the military.

In summary, there is an overwhelming body of early Church literature forbidding Christians from killing. This includes all kinds of killing: murder of the innocent, abortion, just war, and capital punishment. Killing was seen as contrary to God’s law for Christians, even for the guilty. It was seen as a violation of the standard most characteristic of Christians: to love one’s enemy as oneself. After all, if killing is compatible with loving, then what does hatred look like? The ban on Christians killing even extended to Christians serving in their capacity as a representative of the state, such that even Romans 13, so commonly cited by defenders of capital punishment and just war, is not enough to justify Christians killing, even if it is enough to justify non-Christians in government killing. This witness is early, widespread, and clear: all killing is wrong.

The legal justification for 98% of abortions in the UK is that “the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman” (section 1 of the Abortion Act ,1967). The overwhelming majority of these are based on the “mental health” clause. That is, the overwhelming majority of abortions in this country are based on the ostensible risk of mental health to the mother.

But the problem is that there is minimal evidence that abortion has any positive effect on mental health, and some evidence that abortion worsens mental health. This is the conclusion, at least, of the pro-choice atheist David Fergusson, Professor of Psychology at the University of Otago, New Zealand:

“…at the present time there is no credible evidence to support the research hypothesis that abortion reduces any mental health risks associated with unwanted or unplanned pregnancy that come to term…

“These conclusions have important, if uncomfortable, implications for clinical practice and the interpretation of the law in those jurisdictions (England, Wales, Scotland, Australia, New Zealand) which require abortion to be authorized on medical grounds. In these jurisdictions, the great majority of abortions are authorized on mental health grounds… The present re-analysis suggests that, currently, there is no evidence that would support this practice…

“…this conclusion suggests an urgent need to revisit both clinical practice and the law in those jurisdictions in which mental health grounds are the principal criteria for recommending and authorizing abortion. The history of abortion law and law reforms shows that this is likely to resurrect politically uncomfortable and socially divisive debates about access to legal abortion… It is probably awareness of these consequences that explains the almost complete lack of discussion of the evidence for therapeutic benefits of abortion in recent reviews of abortion and mental health. However, it is our view that the growing evidence suggesting that abortion does not have therapeutic benefits cannot be ignored indefinitely, and it is unacceptable for clinicians to authorize large numbers of abortions on grounds for which there is, currently, no scientific evidence.” (David M Fergusson et al (2013), “Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence.” Aust N Z J Psychiatry, 47(9), 819-27.)

This 2013 review comes on the back of several studies by Fergusson and his colleagues, His 2006 cohort study concluded that “[those] having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors.” (David M Fergusson et al (2006), “Abortion in young women and subsequent mental health.” J Child Psychol Psychiatry, 47(1), 16-24.) His 2008 study had a similar conclusion (David M Fergusson et al (2008), “Abortion and mental health disorders: evidence from a 30-year longitudinal study.” Br J Psychiatry, 193(6), 444-51.)

This more recent review surveys a wider range of data from various authors, concluding that “[there] is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.” Fergusson discusses two other recent reviews, one of which concluded that abortion was associated with increased risk of mental health problems, the other of which declared that there was no association either way. The theme common to all 3 reviews, Fergusson notes, is that the evidence linking abortion with better mental health is non-existent.

The implication, Fergusson rightly points out, is that these results render the practice of UK (and other) clinicians thoroughly dubious on legal grounds alone: “Given the high frequency with which mental health grounds are used in these jurisdictions to authorize abortion, it becomes important for both clinical and legislative reasons to examine the evidence on the extent to which abortion has therapeutic benefits that mitigate any mental health effects of unwanted pregnancy.” Clinical practice is often based on specious evidential grounds, but surely rarely as specious as this. If we’re going to put an end to human life, we’d better be sure that we have some very good grounds to do so, and that the evidence supports these grounds. But if the grounds are mental health, and the only evidence we have shows either no association or that abortion damages mental health, then the ideological motivations for clinical decisions become clear, taking precedence not only over the life of the thousands of foetuses aborted in the UK every year, but even over the mental health of those whose lives we can all agree are valuable: the thousands of young women in the UK in this situation. In any other clinical domain, we would have the evidence-based medicine proponents out in droves, lambasting the poor evidential basis for this “treatment”. We would even have legitimate legal cases against doctors who advised or carried out these procedures. But when it comes to abortion, evidence is sacrificed at the altar of women’s choice, and we continue to pour NHS money and effort into these procedures to preserve it.

As a firm pro-choicer, Fergusson has no pro-life axe of his own to grind, and so he recommends a solution: “the most straightforward way of resolving these tensions between the law and clinical practice in jurisdictions that use health criteria as grounds for authorizing abortion is to extend these criteria to include serious threats to the social, educational, or economic wellbeing of the woman and her immediate family as legitimate grounds for authorizing abortion. This revision would more closely align the criteria for authorizing abortion with the multiple personal reasons… for which women seek abortion.”

Of course, such a solution would undermine those doctors within the NHS who want to recommend abortions for any unplanned pregnancy, as well as undermining the NHS’ financial and infrastructural support for abortions. And it would make clear that abortion really has nothing to do with mental health, and everything to do with women’s choice to do what they want with their children (so long as they’re at the politically insignificant end of the birth canal) which, of course, sounds much less like a clinical decision about healthcare when one puts it that way.

Of course, this should not detract from the proper grounds of opposition to abortion. The danger of highlighting various secondary problems in the position and practice of pro-choicers is that they may give the impression that opposition to abortion is really based on things like mental health and taxpayers’ money. Of course, these things are to some small extent relevant, but they occasionally obscure the real reason pro-lifers are against abortion: because abortion is the killing of a member of the human family (and yes, many of us are pro-life in other domains too). None of the secondary arguments are even remotely as important as this. So my point here is not to bolster the case for being pro-life; it is to expose the rampant ideological motivations at the heart of the pro-choice movement ostensibly concerned about women’s mental health. It is to give just one demonstration of the extent to which this ideology has entrenched itself in our society, such that even objective evidence is contradicted in order to pretend that we have some sort of justification for the practice.

Do not be fooled, ladies and gentlemen, into thinking that the pro-choice movement is about women’s health, or that it relies on honest and scientifically substantive tactics and information, or that it makes the most compelling arguments for its cause. Even within the allegedly neutral scientific community, David Fergusson had trouble publishing his results on account of their inconvenience. Fergusson himself expected the link between abortion and poorer mental health to be explained by confounding factors, but his own statistical inquiry led him to believe otherwise, that abortion was an independent risk factor. And, of course, he was asked by his country’s government-appointed Abortion Supervisory Committee not to publish the results in case they were used for political purposes. No prizes for guessing which side they were concerned about using them. All of this should make pro-choicers and clinicians who have not thought about the matter wary. Most of them have simply been indoctrinated while growing up into thinking that abortion is perfectly acceptable, that it is often a clinically beneficial decision, and that there is no way this teaching is just a result of pure, evidentially vacuous ideology on the part of the pro-choice lobby. The fact that we have government committees asking for scientific results not to be published, and that scientifically untenable hypotheses are wholly and unquestioningly endorsed by the medical community (which, in the UK alone, licenses around 200,000 abortions every year), and the fact that the widespread clear-contravention of UK law in clinical practice is virtually ignored should alert us to the fact that there may be something amiss in the pro-choice misinformation thrown onto us and bullied into us as we grow up. And indeed it is.

The simple fact is this: out of nearly 200,000 abortions performed every year in the UK, 97-98% are licensed (and most of those funded) by the NHS on the grounds of risk to mental health of the mother. The only evidence we have shows no connection, or that abortion is independent risk factor for mental health problems, even when the data is corrected for plausible confounding factors. Any other practice so widespread and so contrary to the evidence would rightly be condemned as negligent at best, especially if it involved the killing of human life which, for all we know, could be valuable. But because of the political correctness and expedience of supporting the pro-choice agenda at all costs and against any intellectual, scientific or ethical integrity, the practice persists. Please speak up against it.