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Abortion pills outside medical supervision? That’s just the start

Wed, 2018-05-16 15:38

The current campaign to remove the administration of the abortion pill, misoprostol, from medical supervision and oversight is part of a long-term goal for abortion activists. Their goal is to bypass medical professionals in the process of medical abortion and remove as many legal restrictions on abortion as possible.

This will be achieved step by step. Incremental extension is the name of the game.

A recent BMJ comment piece, celebrating the progress abortion providers believe that they have made towards full decriminalisation and easier access to abortion in the last few years, comments that: ‘A permissive legal framework is not sufficient to ensure access to abortion; skilled, willing providers are [also] essential…’ 

Interestingly, it seems that doctors may be increasingly reticent to be involved in carrying out abortions, thus leaving a potential gap in provision. So a goal for abortion activists is to increase the ‘abortion workforce’ by encouraging and training more doctors in abortion provision and by enabling nurses and midwives to become more involved in abortions, to fill the opening gap.

But that is not all. When more doctors refuse to be involved in aborting their unborn patients, what else is a pro-abortion industry to do?  One answer is direct to patient marketing:

  1. Encourage more self-administration of medical abortions at home
  2. Expand use of medical abortions at home, initially to the first trimester, (not just the first nine weeks), and then beyond
  3. Encourage the two abortion pills (mifepristone and misoprostol) to be given simultaneously, not 24 hours apart.
  4. Greater involvement of nurses and pharmacists in prescribing and providing pills (and doing abortions?), removing doctors from the process.
  5. Encourage women to obtain pills off the internet and to bypass legal restrictions
  6. Encourage women to lie if they cannot get hold of pills from a medical professional or pharmacist (more details below)
  7. Carry out post abortion check-ups simply by using mobile phone apps
  8. Get rid of as many legal restrictions as possible (see here too).

However:

  1. Medical abortions are not as safe as usually implied, especially when self-administered (ie. do-it-yourself). There is limited data on the outcomes of self-administering abortion pills but one peer reviewed study found that 78% of participants had excessive bleeding, 13% had severe anaemia and 5% shock. 63% had incomplete abortion and 23% had failed abortion. They also found that surgical evacuation had to be performed in 68% of the patients, 13% with a blood transfusion. The authors’ conclusion? ‘Unsupervised medical abortion can lead to increased maternal morbidity and mortality.’ If they are so safe, why do medication guides for these pills warn they may cause a number of very serious side effects? And why are they only available in the USA through a restricted medical program (REMS) and only in certain healthcare settings? Furthermore, the medication guides note that there is no research on any possible link to cancer, while a package leaflet for the two pills admits there is only limited data on their use by adolescents.

 Even one of Ireland’s most vociferous campaigners for abortion, obstetrician Peter Bolyan, recently admitted that: ‘there are serious dangers when women take [abortion pills] without supervision. We have knowledge of women who have taken them in excessive dosage and that can result in catastrophe for a woman such as a rupture of the uterus with very significant haemorrhage…And if that happens in the privacy of a woman’s home or perhaps in an apartment somewhere, that can have very, very serious consequences for women. So, it’s really important that these tablets are…dealt with in a supervised way…’

  1. The later in gestation that medical abortions take place, the less effective and the more dangerous they are. Ten weeks is the maximum gestation recommended. Because of increasing uterine sensitivity to misoprostol with advancing gestational age, regimens for medical termination change in the late first trimester and second trimester to repeated, lower doses of misoprostol. The woman’s experience will also be more painful later in gestation, with an exponentially increasing rate of haemorrhage and complications after just seven weeks gestation. Abortion advocates realise that ‘…Gestational age assessment before undergoing medical pregnancy termination is necessary to ensure women take the recommended dose and regimen of medications, and in the appropriate setting’ and yet even they report large variances in self-calculated gestational age. They found that one‐third of women who were followed up after receiving ‘treatment’ had pregnancies of ten weeks gestation or more, when checked by ultrasound. Some even had pregnancies of 18-28 weeks, far off the recommended maximum of ten weeks. 
  1. Taking both medicines at the same time causes more side effects and is less effective than when they are taken at least one day apart – the recommended protocol. One study (by authors who are pro-abortion) found that for women under 49 days’ gestation, the failure rate was 27% if they took the misoprostol immediately after mifepristone. For women between 50-56 days’ gestation, the failure rate was 31%.  The authors of this study strongly recommended that buccal misoprostol not be taken immediately after mifepristone because of the high abortion failure rate. Another study also concluded that a six hour gap ‘…is not as effective at achieving a complete abortion compared with the 36- to 48-hour protocol.’
  1. As noted in a previous blog, self-administration of abortion pills removes any control over who takes the pills, where they are taken, whether they are taken, when in the process they are taken or if an adult is present. It also removes an opportunity to ascertain if abuse or coercion is involved. Little data is available however we know that coercion can take many forms and come from different sources. As well as direct pressure to abort (often from a parent or partner), it can include receiving false information from others, withholding of support from one’s family or emotional blackmail. Several news stories have described abortions forced on a woman by a partner who has given her a drug in food or drink without her knowledge.
  1. Internet abortion providers deliberately encourage women to lie to get hold of abortion pills! One well-known provider states openly on its website: ‘To obtain one of these medicines, one could, for example, say that your grandmother has rheumatoid arthritis so severely she cannot go to the pharmacy herself, and that you do not have money to pay for a doctor to get the prescriptions for the tablets.’ And: ‘In many countries the pharmacy will ask for a prescription from a doctor, but sometimes you can get it without prescription if you are persistent and say it is for an ulcer (Cytotec), or for your grandmother’s arthritis…Don’t stop after the first “no”!’  Women on Waves also ‘helpfully’ shares that Mifeprex can also be bought on the black market.

Women on Web suggests: ‘If there are problems getting the medicines in one pharmacy, try another pharmacy, or a male friend or partner might have fewer problems obtaining them.’ And they say that while Mifepristone is not registered in all countries … this should not be a problem because the medicines are for personal use only. Mifepristone can also be used as a morning-after pill, for the cure of depression, to treat breast cancer etc.’

  1. Follow up using mobile phone apps is highly irresponsible, since complications from medical abortions are common, not rare. I cite above an example of the high rates of haemorrhage after medical abortion and the significant numbers of women requiring surgical follow up. Abortion pill provider, Women on Web, also found from their own surveys that 12–21% of women subsequently needed a surgical intervention and almost half of women who were over twelve weeks gestation (45%), required a surgical intervention. Information about abortion history becomes particularly and critically important when evaluating a woman for infection after abortion and yet, knowing this, Women on Web tell women they can lie to their doctor, and claim they are ‘having a miscarriage’.

In order to increase access to abortions, it seems that abortion-rights advocates have gone from warning of back-street abortions to promoting do-it-yourself black-market ones. So much for the well-worn phrase, ‘Let’s make abortion safe, legal and rare’.

Not only does all this encourage illegal and dangerous practices (including the ability for abusers and pimps to get hold of pills, which can be discounted for packs of ten or more), with no medical professional involved there will be no objective gestational age dating, no guarantee that women read and follow the instructions, no objective screening for the medical and psychological contraindications (more common than for surgical abortion), no medical follow up with scans or visit, no access to emergency services.  And also….no potential malpractice issues to deal with.

Categories: Discussion

Alfie Evans has a progressive incurable illness but his parents should not be stopped from doing what they believe is best for him

Fri, 2018-04-27 09:52

Hear my Premier Radio interview on this case here.

Alfie Evans was admitted to Alder Hey Hospital, Liverpool in December 2016 suffering from seizures. He was found to have a (still undiagnosed) progressive neurodegenerative disease and has now been in a semi-vegetative state for more than a year. During that time, he has been on a ventilator in the critical care unit.

Alder Hey NHS Trust went to the High Court last year to seek a declaration that continued ventilator support was not in Alfie’s ‘best interests’. They claimed that scans showed ‘catastrophic degradation of his brain tissue’ and that further treatment was not only ‘futile’ but also ‘unkind and inhumane’.

But his parents disagreed and wanted permission to fly him to the Bambino Gesu Hospital in Rome in the hope of prolonging his life.

On 20 February, High Court Judge Mr Justice Hayden said doctors could stop providing life support for Alfie against his parents’ wishes, saying the toddler required ‘peace, quiet and privacy’. A lengthy legal battle ensued with the eventual result that Alfie was taken off the ventilator on Monday 23 April.

Over 60 hours later he was still alive breathing spontaneously on oxygen.

The Italian Ministry of Foreign Affairs had previously granted 23-month-old Alfie Italian citizenship, hoping it would allow an ‘immediate transfer to Italy’ but Hayden, who stated that ‘Alfie is a British citizen’ and ‘falls therefore under the jurisdiction of the High Court’, ruled that he could not go. This judgement was upheld on 25 April by three judges at the Court of Appeal.

The case has understandably generated international media interest, intense emotion and accusations on both sides with the medical staff, judiciary, Alfie’s parents and supporters and his legal team all coming in for criticism from various quarters.

Everyone has an opinion, which makes me all the more reluctant to offer mine. I do so now only because I have spent much of yesterday refusing requests to go on adversarial media debates but at the same time having to answer questions from church members, CMF members, leaders of other organisations all over Europe and concerned members of the public who are wanting to know what to think and are deeply concerned about the tone of public discussions. Some of this criticism on both sides, from both media and public, has been particularly vicious and is to my mind inexcusable in what is a deeply complex and difficult case.

In doing so my heart first goes out in particular to Alfie’s parents and the medical staff who have cared for him for so long to the best of their ability under the glare of the media spotlight.

I think there are two key questions with this case  – ‘What is the best way of managing Alfie?’ and ‘Who should ultimately decide what treatment he has?’

They need to be considered separately.

‘What is the best way of managing Alfie?

Alfie has incurable progressive brain damage which will eventually kill him. So, any treatment is only going to be supportive or palliative at best. However, it is not immediately apparent how long he might live either on, or off, a ventilator.

There is an important ethical difference between the active ending of life and the withdrawal of treatment. The former, I believe, is always wrong, whereas the latter is sometimes wrong and sometimes right depending on the clinical circumstances.

It is not always wrong to withdraw or withhold treatment. Sometimes, when death is imminent and inevitable and the burden of the treatment outweighs any benefit it gives, it can be good medicine.

There is a point when we say enough is enough. Similarly, we are not obliged to give every treatment to every patient just because those treatments exist. Doctors are making decisions to withhold or withdraw treatments of various kinds every day.

But these decisions must be made on grounds that the treatment is not worth giving, not that the patient is not worth treating – that the treatment is futile, or that it does more harm than good, rather than that the life is futile. Doctors are obliged to make judgements about the qualities of treatments, but not about the quality of lives. It is therefore sometimes appropriate and ethically defensible to turn off a ventilator in some cases of severe brain damage, just as it is appropriate in other situations to withdraw or withhold drug treatments or surgery.

But, when invasive treatments like ventilators are withheld or withdrawn, basic care including food and fluids (clinically assisted nutrition and hydration), oxygen and symptom relief should continue as it has with Alfie. The fact that Alfie is still breathing after almost 72 hours does not mean that his brain is not severely damaged, only that there is enough function in his brain stem (the respiratory centre) for him to continue the unconscious process of breathing. It does not mean that he is beginning a miraculous recovery, only that his brain stem is currently less badly damaged than his doctors thought.

I am not here making a judgement about whether it was clinically appropriate to stop Alfie’s ventilator as I am not privy to the full clinical details, but Alfie’s doctors clearly felt that it was and made this decision in good faith believing that Alfie was suffering and that the ventilation was providing more burden than benefit.

Other doctors might, and indeed have, disagreed with this conclusion, which tells us at very least that it is not a straightforward assessment.  Personally, I don’t share the view of the court that to keep Alfie on a ventilator is inhumane. If he is deeply unconscious and effectively insensate, then he will not by definition be suffering. On the other hand, the ventilator appears to be simply extending his life rather than improving his underlying brain damage, which is getting steadily worse.

Who should ultimately decide what treatment Alfie has?  

One of the dilemmas Alfie’s case has raised is whether doctors or judges are the right people to determine whether withdrawing life-support treatment is in the ‘best interests’ of a terminally ill child. Should they be able to overrule parents?

Under UK law the rights of parents are not absolute. The 1989 Children’s Act makes it clear that where a child is at risk of harm the state can and should intervene and the court in this case chose to overrule the parents.

It is this that has fuelled the greatest resentment and criticism.

I am not saying that ventilating Alfie was helping him (in terms of improving his condition) but equally I find it hard to see how it was harming him. His doctors may not agree with me and are entitled to their professional opinions. They might equally have argued with some justification (but have chosen not to) that there were other patients more likely to benefit from continued ventilation than Alfie who might have had a greater call on the equipment.

Doctors, of course, like parents, are moral agents and should not be forced to do something they believe is clinically inappropriate or even morally wrong. But Alfie’s parents, in seeking a second opinion elsewhere for their child, are similarly doing what they believe is best for him, even if they are clinging to false hope.

No one is suggesting that they are deliberately doing what they know is not in Alfie’s best interests or that they are incapable of seeking help for him.

Overriding parental responsibility should only be contemplated when a parent is harming a child deliberately or out of ignorance, or failing to care for it adequately. But none of these things apply in this case.

So, I do not see why Alfie’s parents should not be allowed to do what they believe is in the best interests of their son, even if it makes no difference to the eventual outcome of his illness. They are his parents after all.

Based on the clinical details that are in the public domain, it seems most likely that Alfie will continue his downward trajectory and die, but if his parents wish to try other treatment options and there are others who are prepared both to take on his treatment and also to pay for it, then the hospital and the courts should not stand in their way.

In doing so they risk appearing paternalistic and controlling and thereby doing huge damage to their own, and our country’s, reputation.

When a doctor or judge in good faith opts not to treat a child because he believes it is not right or appropriate to do so he (or she) should be respected in that professional judgement. But he should not be able to stand in the way of a second opinion being sought by the child’s equally committed parents.

Categories: Discussion