If abortion laws are not to eventually go across the board the liberals and conservatives need to dialogue systematically and reasonably and meet on common ground. This is not a measure about “harm control” but a measure which respects human rights. Political parties need to argue with reason and expertise and not merely take sides on liberty and conservatism. There are three areas, as far as I can see, which need discussion.

Danger to the mother The recent case of a woman who was sent abroad is clearly a warning sign. The doctors did the right thing to refer for legal advice and according to law it could not be done, at least not without a more specified law. As things stand an induction of labour may have been considered to be an abortion. We do not know the full details other than from the media. From what I gather the baby was non-viable and the woman’s waters had broken. I read that she was, or was at risk of, bleeding and this may lead to dire consequences, from septic shock to death. I hear also that she has opened a case in the court of law. Although as things stand, she will probably lose the case, it will certainly be used as a springboard for the pro-choice movement. Someday a tragedy may happen, as did in Ireland. At least that will probably be the argument.

In reality the issue, as per the case of Savita Halappanavar in Ireland, philosophers agree that the issue fell clearly under the Principle of Double Effect. The problem with this principle is that although it is a legitimate and a morally accepted philosophical principle, it was written by Thomas Aquinas and in fact usually referred to as the Doctrine of double effect. It is problematic because at the end of the day, for Catholic doctors, it is the Church which has to accept when and where it can be used as its four conditions need to be satisfied with utmost rigour. The up-side is that it can be discussed and probably, to aid the law, the department of theology can help in determining this through an Episcopal conference. Failing this, legislators have to make the call.

The four conditions of the principle of double effect serve well for ectopic pregnancy (a tubal pregnancy) and for receiving treatment for disease, including cancer, even if this causes harm to the baby – a little bit harsh in my opinion, but some consider that the baby is worth saving even if it is severely affected and perhaps deformed by the chemotherapy. These are decisions which, by right, ought to be left in the hands of the mother or parents.

In this case we have clearly an issue where the baby will die, unless, of course, the baby is considered viable. At less than six months, the lungs are too small for it to survive. If the waiting for viability of the fetus is short it may be worth the risk. I am sure that the mother would not purposely choose to kill and chances the baby surviving. In the Savita case, it was certain that the baby was going to die. I am here assuming that in the local case (which of course may not be the case if the details are different) the baby was going to die too. When we remove a tubal pregnancy we remove a live fetus, which cannot survive in that environment. In fact, it may survive but as it gets bigger the tube will rupture and it will die. So the live fetus is removed with the surrounding pathological tissue – the tube.

Taken from the online Stanford encyclopaedia the following quote explains the Principle of Double Effect well:

The New Catholic Encyclopedia provides four conditions for the application of the principle of double effect:

1. The act itself must be morally good or at least indifferent
2. The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary
3. The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed.
4. The good effect must be sufficiently desirable to compensate for the allowing of the bad effect

In the case concerned the action is in itself good as the intention is to save or protect the life of the mother (even if one assumes that there may be chances for the fetus, one has to put into the equation the severity of the risks the mother has to endure and therefore patients’ rights dictate that she has to decide). Secondly, the agent is certainly not intending to kill the baby as would be the case in “normal” abortion. The intention is the safety of the mother and the fact that the baby has smaller chances of survival. The good does flow from the bad effect. Medical induction of delivery is frequently done. The problem here is the non-viability when there is still a heartbeat. This is the main argument to be discussed. What is more important here is, what rights ought the mother to have? Finally, the fourth condition is clear – the good effect is sufficiently desirable to compensate for the bad. Here we have to balance paternalism (or maternalism, depending on the case) versus the rights of the patient.

Cases of Rape Of course, one assumes here that the woman reports the case in good time. This may not always be possible but certainly a doctor’s examination and a police report will support. I am not sure that a case made for someone having consensual sex and suddenly says “no” may hold in all cases. But it should be clear in cases of clear-cut rape – the word strong meaning that the woman was involuntarily held, her clothes ripped and then raped. This assault should not be tolerated and having myself contemplated this for many years, I believe that society has no right to take away the decision from the woman. Under-age girls should always be considered cases of rape since at law they are not considered legally mature to give consent, especially if they come from a dubious socio-economic background. Society must be willing to make this sacrifice of one innocent for another. There is proportionality.

Of course, this may be difficult to digest, but if we are to treat women equally it should be in place. We have to admit that rules were indeed made by paternalistic institutions and societies in the past. Not an easy issue. But dialogue does require the two sides to move towards some common ground at law.

Health issues  Not all health issues can be used as an excuse. This has verging on the abuse in the UK in the past, as some reports have suspected. The liberal side has to agree to this. Movement cannot be made by one side only. A single mother who already has three children and whose fourth pregnancy may send her into bankruptcy may be a strong case. If the government had to provide support, experience shows that this can be abused in many ways, as we have seen for single mothers who continue to live with their partner in order to receive benefits, or in the past, when they got preferential treatment to get into a Church school.

Abortion is not sacred, as many are saying. We do not have control over our bodies if it affects other people. This is why we are not allowed to sell organs – it becomes a market value and the more vulnerable will be the victims to sell. One cannot honestly believe that developing babies, especially when you already have a human form, are not persons in their own right. This is why we have an Embryo Protection Act. But the current pro-choice is deliberately not discussing the status of the embryo. But where patients’ rights and reproductive rights are violated a compromise is imperative (unless the conservative prefer to lose all eventually). It is not damage control. It is about rights, solidarity and human respect.

I confess to be pro-life. I do not consider abortion in general as a reproductive right – it is not; reproduction has already occurred. Humans gestate inside their bodies like all mammals and not in an outside-the-body egg. But rape, and some other cases, are indeed a violation of reproductive rights. There was no consent. There was violence. There is psychological damage and currently psychological damage caused by a society driven by a construct that says a fetus is always more important than the mother. Surely we can admit that sometimes we have to allow the woman to decide. If we do not dialogue however, the women who are accusing men that they are being used as incubators and only good to have children, will have proven their point.

These are merely points for discussion. It pains me as a pro-lifer but ethics is about dilemmas which bring us together in discussion. It should not be a battle ground, which deceives the ends of ethics anyway. Dilemmas are about logical dialogue and about meeting common normative values.

Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches at the University of Malta. He chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee. Email: [email protected]

This article is his personal opinion and does not represent the opinion of any committee or Board he serves on