Warning: potentially upsetting discussion on terminations
This morning as I was coming to the end of a very busy on call shift when a young girl was wheeled onto the gynae ward on a stretcher. She was bleeding heavily and had a worryingly high heart rate and low blood pressure suggesting she had lost a lot of blood and that her body wasn't coping. Reading her admission notes it appeared she had been bleeding heavily like this for 2 days. She was in early pregnancy and had taken some home-made drugs to induce an abortion. Whilst this had been partially successful she was now having a life threatening bleed. On examining her I found an intact gestational sac sitting in her underpants, with two tiny babies floating in the amniotic fluid. Their placentas however remained within the uterus, and until they came out (with quite some difficulty and a long, painful procedure) she continued to bleed.
Had this school girl not been able to get to the hospital this morning I am confident she would have died from a catastrophic bleed. I do these 24h on calls approximately 1 in 3 days, and most shifts I see a patient who I am highly suspicious has taken something to induce a termination, although she was unusual to have admitted it. Most often they come in bleeding heavily and I am able to stop that bleeding with an MVA procedure, but we have had a few young girls die because they have perforated their uteruses and bowels by sticking sticks inside...
Unsurprisingly, something that I am really pondering at the moment is the ethics of terminations. When I get back to the UK I'll be starting the obs & gynae training program and one of the services gynaecologists provide is terminations. So I need to get my head around what I do and do not want to do before I start on this program.
When I was a teenager if you asked me whether I would ever perform abortions I would have said absolutely not, black and white. However having seen similar cases to the above during my elective in Ghana I began to realise nothing is quite that straight forward. Whilst terminations are actually legal in Zambia with similar laws to the UK, access to them is very poor and education about safe sex is distinctly lacking. Having been founded as a mission hospital, Saint Francis does not provide this service.
At one point during my time here I came to the conclusion that while it makes me a little uncomfortable, a termination service alongside better sex education is essential for preventing the deaths that I have seen and that this girl was lucky to have avoided. But I don't want to be a hypocrite. If I think it is necessary for this service to be provided then I ought to be willing to provide it. And that makes me uncomfortable. So I have really been grappling with these ideas.
After a lot of discussion with friends on the subject I have come to the following conclusion. Before I state that conclusion, I'd just like to say that I reserve the right to change my mind in the future. I don't think I should have to state this, since it should be obvious that anyone who is using any kind of analytical reasoning will naturally be open to coming to a difficult conclusion if their exposures change, but our society often seems to be unwilling to recognise this. And secondly I would like to state that in saying all of this I in no way condemn anyone who has come to a different conclusion to me, who has made the difficult decision to have a termination, or who performs them; I'm merely showing my current, personal thoughts on the matter.
My conclusion is this: you have to decide, do you think a termination is removing something that is just a bunch of cells or do you think it is a baby? Because if you think it is just a bunch of cells, then it's no different than having your gallbladder or appendix removed. No one is protesting against the right for gallbladders to live. It is a woman's right to have her appendix or gallbladder removed, so if that fetus is just a bunch of cells I can see why many view it as a woman's right to have those cells removed. But if you believe it is a baby then really ending that baby's life is no different than ending any other humans life. There's obviously a lot more to this debate, slippery slope argument etc. etc., but what I'm talking about is personal conviction, not legislation. And from a personal conviction point of view, I think this really is the crux of that matter.
And right here and now, on 21st May 2017, my thoughts are that it is a baby. So I don't want to end its life.
However things do get a bit murky. What about the morning after pill? That has been described as some as an abortive form of contraception as it prevents implantation after fertilisation has already happened (really the whole point of it, being the morning after). As do some other forms of hormonal contraception. Full disclosure: I have twice in the last few weeks prescribed the morning after pill, for a 13 year old girl and a 15 year old girl who had both been raped by older men. At the time I had no qualms about this: the idea of either of them falling pregnant seemed abhorrent. Although I suppose my ethics shouldn't be prescribed by my emotions?
You could argue that that is no different than doing a termination at, for example, 10 weeks gestation. Should gestation make a difference? If so, where do you draw the line? One small difference, I suppose, is that in these cases they may not have ovulated and therefore conception may not have happened, whereas at 10 weeks you have a confirmed heart beat. But ovulation may well have happened or I wouldn't have prescribed the drug...
Then there's the case of a ruptured ectopic we had a couple of days ago where the fetus was confirmed still alive by ultrasound scan. The baby would have died shortly anyway and the mother most likely would have too, so there is very good reason for my colleagues to have performed that operation, and I don't think there are many who would disagree, but it is still ethically challenging when you think about what's really happening.
So I have a lot of questions and not many answers. But I do think there is a lot more to this 'debate' than people often give it credit for. One of the purposes of writing this, as well as simply to provoke thought, is to hear your opinions on these questions. I'm a little nervous, because internet discussions about these things can be a little risky, but I value your opinions and really do need to come to some firm conclusions before October. If you do want to weigh in on this, please remember - approximately 1 in 4 pregnancies ends in a termination, so many, many people you know will have had one - 1.6% of 15-44 year olds have a termination each year, so please be kind.
This morning as I was coming to the end of a very busy on call shift when a young girl was wheeled onto the gynae ward on a stretcher. She was bleeding heavily and had a worryingly high heart rate and low blood pressure suggesting she had lost a lot of blood and that her body wasn't coping. Reading her admission notes it appeared she had been bleeding heavily like this for 2 days. She was in early pregnancy and had taken some home-made drugs to induce an abortion. Whilst this had been partially successful she was now having a life threatening bleed. On examining her I found an intact gestational sac sitting in her underpants, with two tiny babies floating in the amniotic fluid. Their placentas however remained within the uterus, and until they came out (with quite some difficulty and a long, painful procedure) she continued to bleed.
Had this school girl not been able to get to the hospital this morning I am confident she would have died from a catastrophic bleed. I do these 24h on calls approximately 1 in 3 days, and most shifts I see a patient who I am highly suspicious has taken something to induce a termination, although she was unusual to have admitted it. Most often they come in bleeding heavily and I am able to stop that bleeding with an MVA procedure, but we have had a few young girls die because they have perforated their uteruses and bowels by sticking sticks inside...
Unsurprisingly, something that I am really pondering at the moment is the ethics of terminations. When I get back to the UK I'll be starting the obs & gynae training program and one of the services gynaecologists provide is terminations. So I need to get my head around what I do and do not want to do before I start on this program.
When I was a teenager if you asked me whether I would ever perform abortions I would have said absolutely not, black and white. However having seen similar cases to the above during my elective in Ghana I began to realise nothing is quite that straight forward. Whilst terminations are actually legal in Zambia with similar laws to the UK, access to them is very poor and education about safe sex is distinctly lacking. Having been founded as a mission hospital, Saint Francis does not provide this service.
At one point during my time here I came to the conclusion that while it makes me a little uncomfortable, a termination service alongside better sex education is essential for preventing the deaths that I have seen and that this girl was lucky to have avoided. But I don't want to be a hypocrite. If I think it is necessary for this service to be provided then I ought to be willing to provide it. And that makes me uncomfortable. So I have really been grappling with these ideas.
After a lot of discussion with friends on the subject I have come to the following conclusion. Before I state that conclusion, I'd just like to say that I reserve the right to change my mind in the future. I don't think I should have to state this, since it should be obvious that anyone who is using any kind of analytical reasoning will naturally be open to coming to a difficult conclusion if their exposures change, but our society often seems to be unwilling to recognise this. And secondly I would like to state that in saying all of this I in no way condemn anyone who has come to a different conclusion to me, who has made the difficult decision to have a termination, or who performs them; I'm merely showing my current, personal thoughts on the matter.
My conclusion is this: you have to decide, do you think a termination is removing something that is just a bunch of cells or do you think it is a baby? Because if you think it is just a bunch of cells, then it's no different than having your gallbladder or appendix removed. No one is protesting against the right for gallbladders to live. It is a woman's right to have her appendix or gallbladder removed, so if that fetus is just a bunch of cells I can see why many view it as a woman's right to have those cells removed. But if you believe it is a baby then really ending that baby's life is no different than ending any other humans life. There's obviously a lot more to this debate, slippery slope argument etc. etc., but what I'm talking about is personal conviction, not legislation. And from a personal conviction point of view, I think this really is the crux of that matter.
And right here and now, on 21st May 2017, my thoughts are that it is a baby. So I don't want to end its life.
However things do get a bit murky. What about the morning after pill? That has been described as some as an abortive form of contraception as it prevents implantation after fertilisation has already happened (really the whole point of it, being the morning after). As do some other forms of hormonal contraception. Full disclosure: I have twice in the last few weeks prescribed the morning after pill, for a 13 year old girl and a 15 year old girl who had both been raped by older men. At the time I had no qualms about this: the idea of either of them falling pregnant seemed abhorrent. Although I suppose my ethics shouldn't be prescribed by my emotions?
You could argue that that is no different than doing a termination at, for example, 10 weeks gestation. Should gestation make a difference? If so, where do you draw the line? One small difference, I suppose, is that in these cases they may not have ovulated and therefore conception may not have happened, whereas at 10 weeks you have a confirmed heart beat. But ovulation may well have happened or I wouldn't have prescribed the drug...
Then there's the case of a ruptured ectopic we had a couple of days ago where the fetus was confirmed still alive by ultrasound scan. The baby would have died shortly anyway and the mother most likely would have too, so there is very good reason for my colleagues to have performed that operation, and I don't think there are many who would disagree, but it is still ethically challenging when you think about what's really happening.
So I have a lot of questions and not many answers. But I do think there is a lot more to this 'debate' than people often give it credit for. One of the purposes of writing this, as well as simply to provoke thought, is to hear your opinions on these questions. I'm a little nervous, because internet discussions about these things can be a little risky, but I value your opinions and really do need to come to some firm conclusions before October. If you do want to weigh in on this, please remember - approximately 1 in 4 pregnancies ends in a termination, so many, many people you know will have had one - 1.6% of 15-44 year olds have a termination each year, so please be kind.
