Challenging the abortion taboo | Isabel Stabile

It’s been a year since Doctors For Choice was launched, in a country where pro-choice views were previously limited only to isolated voices. In your view, has the emergence of a professional NGO made any substantial difference to the local discussion on abortion over the past year?

Yes, definitely. More and more people - especially young people - are engaging with our message through social media.

Doctors for Choice advocates for safe, equitable, and accessible sexual and reproductive healthcare in Malta. Our main aims are to achieve: comprehensive sexual and reproductive education; comprehensive and freely accessible contraception; the decriminalisation of abortion; and changes to the law to allow the provision of safe, equitable, and accessible abortion services.

Locally, however, any discussion about abortion has also been taboo within Malta’s medical community: perhaps even to a greater extent. This despite the fact that doctors in Malta inevitably have to deal with women seeking abortions and post-abortion care.

And yet, a 2019 study among 454 local doctors in Malta has also shown that the majority actually agree that abortion should be legalised in limited circumstances; such as when a woman’s life is in danger, or in cases of terminal fetal anomalies.

The setting up of Doctors for Choice has certainly started a conversation amongst Maltese medical doctors as well as future doctors, among whom we have a great deal of support.

For the first time in Malta’s history, the public can now reach out (anonymously, if necessary) to a local organisation for reliable evidence-based information on abortion and reproductive health, that is in line with the recommendations of reputable health organisations including the World Health Organisation and the Royal College of Gynaecologists.

So yes, we believe that the organisation is helping to make people think differently about the issue of abortion and also changing women’s experience for the better by giving them the assistance they need based on reliable information and resources.

The pro-choice argument is often countered by the general view that ’life begins at conception’; and that, therefore, a newly conceived embryo should have the same rights as a fully developed human being. Do you consider this a misconception… and if so, why?

This is a long-held misconception. Life is a continuum. Sharp boundaries may be convenient, but they are inadequate and arbitrary. Like many biological developments (when exactly does one become middle-aged or mature?), the transition from fertilised egg to adult human is shown by a steady upward curve.

In the words of the British philosopher Johnathan Glover, known for his books and studies on ethics, the contention that a fertilised egg is equivalent to a person is a “morally motivated piece of conceptual revision”. I share Glover’s view that the “life begins at conception” argument is based on the prior belief (often promulgated by the Catholic church) about how an egg ought to be treated.

In terms of the rights of an early embryo/fetus, philosopher Michael Tooley has argued that “bearers of rights must at least have the capacity to desire what they have a right to”. We know that awareness requires a sophisticated neural network, which has been shown to develop by around six months of pregnancy. Given that these neural pathways are not yet developed, the concept that the early embryo/fetus could possibly be aware of its own existence seems very far-fetched.

Also, pro-life campaigners often tout the importance of the rights of the fetus. In actual fact, the fetus obtains legal rights at birth. So denying an abortion in circumstances such as rape and incest, would give more legal rights to the fetus than to the mother.

We certainly respect the views of those who believe that life begins at conception (presumably, all those who believe in the sanctity of human life are also absolute pacifists, and would never kill anyone, not even in self-defence).

Based on scientific evidence, however, we have different views, and as doctors we believe we should be allowed to offer the option of abortion legally and safely to those women who share these views.

Allow me to please share my aversion for the use of the term ‘pre-born’ for the developing embryo/fetus by many pro-life campaigners. I would only accept that description if we refer to all newborns as ‘pre-dead’!

You say that Malta’s abortion laws make no exception, not even when the mother’s life or health is at risk. Yet local pro-life doctors argue that in practice, the Thomist ‘double effect’ principle is applied in such cases (whereby it is permissible to cause harm as an unintended side effect of bringing about a good result): making any extra legal provisions superfluous. How do you respond to that argument?

Yes, the ‘principle of double-effect’ - which is an ethical concept that originated in Catholic philosophy - is applied locally in such cases. However, our criminal code makes no mention of this principle, and does not distinguish between ‘direct’ and ‘indirect’ termination: or any differences in the ‘intention’.

When medical doctors follow this principle in the management of cases when the mother’s life or health is at risk, they are not in compliance with the law as it stands. That is why we believe that there should be a law that states that if the mother’s life or health is in danger, then she should have the right to decide her own management, including the option of abortion.    

Ireland recently legislated to legalise abortion, largely as a result of the Savita Halappanavar case: where a young woman died as a result of pregnancy complications, after having been denied an abortion in hospital. Under Malta’s present legal set-up (which is similar to Ireland’s, before the amendment) could the same thing happen here?

Yes, it could.  The lack of a clear legal framework, as well as the lack of policy guidelines on when the ‘double-effect’ principle can be invoked, can have a huge impact on patient care. It may also lead to medical professionals being reluctant to make clinically sound decisions to terminate a pregnancy which is threatening a woman’s life.

For example, the point at which the status of an ill patient changes from being ‘very sick’ to ‘dying’ is not only unclear, but entirely arbitrary.  Waiting until the situation is considered serious enough before intervening to prevent a fatality, may well be too late.

Just because we have not as yet had such a case (or at least, not to our knowledge), does not mean this could not happen. The most crucial aspect is that women should be in a position where they are able to contribute to the management plan of their own pregnancy in a timely manner.

If it happened in Ireland where there was (at the time) a legal ban on abortion, it can happen anywhere else with similar restrictive laws. The only way to ensure that this does not happen is to eliminate the total legal ban on abortion.

Malta’s laws also threaten doctors with criminal sanctions for performing or assisting abortions. Can you give some practical examples of how this provision actually affects doctors in the course of their work?

Clinical decisions that are based on attempts to quantify risk may result in harming women. One example of this situation is widespread infection in a patient with PPROM (pre-term premature rupture of membranes).

This is particularly problematic if the pregnancy is less than 24 weeks, which is generally regarded as the lower limit of fetal viability. Inducing delivery prior to this stage, say at 17 weeks, basically amounts to an abortion.

With our current laws, there is no option for such patients to decide for themselves if and when they wish to terminate the pregnancy. Instead, the medical team would use the ‘principle of double-effect’ as a loophole, wait until the situation worsens (such as the patient being in medical shock), and then perform a life-saving termination of pregnancy  to try to prevent maternal death… when it may well be too late.

In such cases, medical professionals in Malta are technically performing a criminal act… even if, in practice, this does not lead to criminal conviction.

Doctors For Choice argue that the lack of access to safe abortion does not stop abortions from happening, but makes them less safe for women. Is there any evidence of unsafe abortions taking place in Malta today?

The complete ban on abortion not only impacts the patient-doctor relationship, but also the advice provided to women with an unwanted pregnancy, or a pregnancy complicated by poor health of the woman or a fetal anomaly (even if wanted).

This ban also affects the quality of post-abortion care as many of those who do have abortions by travelling or using pills cannot obtain the same follow-up as women in countries where abortion is legal. This in itself is unsafe.

If left with no options, some women will get desperate and may attempt unsafe abortions. However, since most women in this situation in Malta would either obtain abortion pills online or travel to another country, this is probably unlikely; but certainly not impossible.

Needless to say this is not ideal, as women who seek abortion face the risk of being criminalised and may therefore be reluctant to seek help in case of rare complications.

We are also particularly concerned that some women are procuring medical abortion pills without receiving enough information about potential complications. Furthermore, the current COVID-19 travel restrictions further limit the options for women in Malta.    

There is also an argument that our total abortion ban results in discrimination among different socio-economic strata. Women with financial means can travel, while those without means have very limited options. Do you also see the pro-choice campaign as an issue of social justice, and not just health?

Absolutely. There is no doubt that the total legal ban on abortion discriminates against women in certain groups in society: e.g., those who cannot afford to travel, those who have mobility issues such as migrant women without visas and women in abusive relationships.

With the COVID-19 travel restrictions, the distinction between those who can and cannot afford to travel has become somewhat blurred; and this is also why so many more women are now resorting to ordering abortion pills online. However, the very poor, or those in marginalised groups, will always inevitably suffer more without the support of the state. Not only is this an issue of social justice, but also of human rights.

Lastly: despite the recent emergence of lobbies such as Doctors For Choice, surveys continue to indicate a strong pro-life sentiment in Malta, and government continues to treat the subject as taboo. Do you feel that it may be premature to expect any legal changes at this stage?

Matters of essential healthcare, as recognised by the WHO and all other international medical bodies, should not be decided by any majority. We believe that in order to attain the best public health outcomes, women must have access to safe abortion, irrespective of the views of various population groups. Not all Maltese are Catholic!

With so many people in Malta opposing abortion, even in the context of essential healthcare, politicians will be reluctant to address this issue openly, as they see it as a threat to their political advancements. So we expect it will take time to see the decriminalisation of abortion in Malta.

But there are, in fact, many more people in Malta who are pro-choice than you would think. A year ago, no one would have thought that a pro-choice Facebook page like Doctors for Choice Malta would get such a large following, with over 7,500 likes; 86% (i.e. almost 6,500 likes) of these being people residing in Malta.