Abortion: a medical, not a political issue | Matthew Drake

Recently, a group of medical professionals emerged to challenge the legal status of abortion in Malta. Can you tell us why medical professionals felt the need to form ‘Doctors For Choice’? Why was it necessary to take a public stand on this issue?

There are a lot of levels to that question; I think that every one of us has a personal reason, on some level: be it vaguely related to an experience they’ve had themselves, or someone they know. You could also look at it as an act of rebellion, in a sense. We’ve grown up in a country where, for all our lives, abortion has been a ‘special subject’ that we can’t really talk about. And once we became doctors… we found that we could talk about it even less. We can’t even discuss it among ourselves. It’s never mentioned. We were never taught about it at university: not a single lecture… in my experience, anyway. So in a way, it is an act of rebellion against this culture of omerta’. But the main reason, by far, is that we see a great need for termination of pregnancy services in Malta… and, more broadly, for sexual/reproductive health services as a whole. Sex education, to be frank, is rubbish: everybody knows this. Access to contraception is minimal… and none of it is free. Added to all this, there is also a social justice dimension.

You hear stories about Maltese women who go abroad to terminate their pregnancy, for whatever reason. And then you see the other side of the coin. Other Maltese women who desperately ask for termination of pregnancy services locally; who are denied counselling; denied referrals… These are people who know next to nothing about sexual health. They know nothing about contraception. They do not have the money to go abroad. They do not have the education to make informed choices. In many cases they will not have the family support networks enjoyed by others. To me, this is a clear case of social injustice. Those who go abroad for an abortion, do so because they can. Those who don’t have the money, the education, the support… they can’t. It’s unfair.

Nonetheless, those who see abortion as an intrinsic evil will counter-argue that all abortions should remain illegal, for rich and poor alike. How would you respond to that?

There is a lot of evidence that criminalising abortion does not stop abortions from happening, by any stretch. All it does is create a dichotomy; and it creates a major health risk for people who cannot access that service by going elsewhere. This is, in fact, a health issue, and I think It should be completely medicalised. It should not be politicised. Religion should not be involved. Morality shouldn’t be involved, in my opinion. It should be treated as a medical issue: like having a knee- or hip-replacement, or being treated for hypertension…

Sticking to that same perspective: some people might be shocked by the comparison between an abortion and, for instance, a hip-replacement operation. Isn’t there also the issue of terminating a human life?

I want to be clear: I am comparing termination of pregnancy services to other procedures and medications, solely in the sense that they should be available; they should be safe; and they should be treated as a medical procedure, and not as something else. I understand that there is much greater sensitivity surrounding this issue; I don’t think it’s an easy decision for anyone to make. I sympathise with both the doctors performing or offering the procedure; and with the women seeking it. It’s a sensitive issue. Just as sensitive as trying to get pregnant and start a family. Just as sensitive, perhaps, as watching a loved one pass away, slowly and painfully. All these sensitivities are there, embedded in this hot potato of an issue…

You say it ‘shouldn’t be politicised’, but – like it or not – it has. We’re in the last week of an election campaign, which has been described as a ‘referendum on abortion’. How do you react to political arguments about abortion? Can you also give an indication, from your experience, of how other doctors view this?

With regard to other medical professionals I have spoken to: I have to say that I am flabbergasted – truly flabbergasted – by what I see and hear. Let me give a small preamble: we, as doctors, practise what we call ‘evidence-based medicine’. This may not be obvious to everyone. But what it means is that: the way we manage patients is based on the hard graft of the tonnes and tonnes of research – conducted by thousands of people throughout history, and always ongoing – into the natural causes of disease; what treatments work best; what drugs or procedures to prescribe, and so on.

This is the really hard work we do as doctors; this is what we base our entire practice on. If you were a fly on the wall in any clinic or hospital, and listened to doctors talking among themselves, you would hear a lot of: ‘But that doesn’t follow the guidelines. The guidelines say…’, or ‘The evidence shows this, or doesn’t show that…’ That is the sort of discussion you would hear. It will be about ‘what the latest evidence tells us’; what the best practice is, according to the latest research. Why are we not doing that with reproductive health? I cannot understand this. I cannot understand doctors who say that they disagree with decriminalising abortion… but then, when I ask them, ‘But how can you, as a doctor practising evidence-based medicine in every other sphere of your profession, simply cherry-pick, and choose to disagree when it comes to this – and only this – issue?’ How can they choose to ignore the evidence: when there is such a wealth of evidence, from all the major international health organisations?

What sort of reaction do you get to that question?

Most of the arguments I’ve heard are, roughly, that ‘life starts at conception’; that ‘the human embryo, or zygote, is a human being, with its own DNA, and should be treated the same as a 12-year-old, or 30-year-old, or 80-year-old human being.’ Now: personally speaking – I can’t speak on behalf of anyone else, on this – yes. We all have the same DNA. Yes, the embryo has the potential to go on to be born, and ideally live to a ripe old age.

Life is a process; from the moment the sperm meets the ova, the process begins. So, to arbitrarily draw a line, as to ‘where that life starts’… I don’t think that’s the issue here. The issue is not ‘where life starts’. It is not ‘what is a person?’. There is no definitive evidence to base any answer on. If anyone tells you, ‘science has proven what a person is…’, it’s nonsense. Science doesn’t even go into that: ‘what is a person’ is a philosophical question, not a scientific one. The background we come from is a medical background. What matters to us is the health of society. And the end goal of all medicine is public health, full-stop. So the question really is: what changes public health outcomes? There is plenty of evidence for this; we do know what changes the health of society. So why are we not implementing this knowledge in this area? It is a question I’d like to ask both to my fellow colleagues in the profession, and also to legislators who legislate on public health. Why are we disregarding all this medical evidence, simply for the sake of… I don’t know what?

On the subject of legislation: Maltese law threatens up to four years in prison for any woman who terminates her pregnancy; and also for anyone who helps a woman achieve that goal. Technically, even referring patients to clinics overseas (for example) might be interpreted as a crime. Does this affect the way doctors go about their job?

I can’t give you an evidence-based answer to that, because quite frankly there is no research or data that I am aware of. I do not work in the obstetrics department myself; but I have studied in it, I know doctors who work there… I am familiar with the context. And the general sensation is that it is all ‘hush-hush’. It’s something no one really wants to talk about. There is a lot of secrecy, a lot of omerta’.

What I’m glad about is that recent developments – including the formation of our own group, but also Voices For Choice, and the pro-choice coalition – have lessened the stigma associated with the issue. There is more of a conversation going on, and I think people have been emboldened… slightly… by all this. But legally, there is still the sense that, if doctors assist a woman in acquiring a termination of pregnancy, they will be liable to four years in prison. Now: I don’t know of any arrests ever having been made. I have spoken to lawyers who said ‘it is only applicable if the abortion happens on Maltese soil.’

So, I don’t think it can be applied to cases where patients are referred to clinics abroad. But in terms of a robust system of information, or referrals and counselling… it simply doesn’t exist here. I know of cases – anecdotally, I must stress – where women have come in, heavily pregnant; bleeding from their genitals; basically, all the symptoms of a late-term still-birth. In one recent case I’ve heard about, when the foetus was delivered, it was found to have a laceration, or incision, around the scapula. It is obvious to anyone with a pair of eyes what happened. Exactly how it happened… whether using a knife, or who knows what else… we might not know for sure. But you don’t have to be a doctor to understand what happened to that woman…

How are such cases dealt with?

The discussion, between the doctors handling this case, was to say… ‘Ah, well.’ They just documented it, and that’s it. But… was that woman arrested? Were the police alerted? No. So the question I want to ask the entire Maltese population, at this stage, is: do you agree that a woman who tries to terminate her pregnancy – or wants to terminate her pregnancy, and asks questions about it – should be put in prison? Because as it is, the law says that that woman’s place is in prison. Do we, as a nation, agree with that? I have a sneaking suspicion that a good percentage of the Maltese people will say ‘No’ to that.

And that is how it works in practice: doctors do not call the police in to arrest women in such circumstances. The law, in practice, doesn’t even work. So why not change at least that aspect of it? Why not at last decriminalise?

From the circumstances you describe (and separate evidence), it is clear that ‘back-street abortions’ do take place in Malta. How serious is the health risk posed to women by the law as it stands today?

One of the things that emerged from the European Health Consumer index, published last February, is that Malta has gone down 10 places – to 27 out of 35 countries – in terms of [public health]. Commenting on this, Health Minister Chris Fearne said that the drop was: ‘because we do not offer termination of pregnancy services in Malta. We have more children with serious medical problems, and that puts us behind’.

And he’s right. The European average for infant mortality is 3.6 per 1,000. In Malta, it’s 5.78 per 1,000. That’s more than two infant mortalities above the European average. There are around 4,000 live births per year here. Taking into consideration those extra two mortalities, around 23 live-birth infants die each year. From this, we can extrapolate – though, once again, we have no reliable data – that some of those cases will be due to serous foetal anomalies, which in other countries might have been terminated. It would work out at around eight per year… not a scientific conclusion, granted; but let us, for argument’s sake, say that it is eight per year.

Those are eight infant deaths more than the European average, which could have been prevented from reaching that stage. Not to mention the other human costs involved that could also have been prevented: from the medical expenses, to all the emotional sacrifices that would have been made by the woman, and the family, with regard to these deaths. That’s one thing to consider.

But the same report also states that ‘legal restrictions to termination of pregnancy do not stop them from happening, but rather turn them into a major health risk: forcing women to go abroad, or have an abortion under obscure, insecure conditions.’

That is the conclusion of the European Health Consumer Index study; and it is also what the World Health Organisation, the Royal College of Obstetricians and Gynaecologists, and the Federation of International Gynaecologists and Obstetricians all state in their own, very lengthy evidence-based reports.

There is so much evidence indicating that, by making it illegal, you will not stop it from happening; you will not stop people from seeking it; and you will not stop it from being necessary, from a medical, psychological and social dimension. But we’re not looking at any of that evidence; we are not adopting an evidence-based approach to this issue. So, I’ll return to my previous question. Is that woman’s place in prison? No, it isn’t. I think most people will agree with that.