My colleague, Prof. Pierre Mallia, argues persuasively that dialogue is needed as the country considers eliminating its archaic total ban on abortion. I fully agree. However, I must take exception to his description of rape as a scenario where the woman is held against her will, her clothes are ripped, probably by a stranger off the street. This sequence of events plays into the false assumption that if her clothes were not torn, she perhaps even invited the attack. He also questions whether a sexual encounter counts as a rape if a person says “no” even after relations start consensually. On the contrary, consent is essential throughout any sexual encounter and forcing someone to continue after they have expressed their reluctance to do so is rape. Most rapes are carried out by people known to the victim, including relatives, partners and friends, and sadly, anyone from any social background can experience rape. It is time to change the discourse about rape and teach everyone, starting from childhood how to behave respectfully around others.

Returning to the topic of abortion, in the opinion of Professor Mallia, the philosophical doctrine of double effect can and should be used to justify ending a pregnancy which is ectopic (where the embryo/fetus will die), or if the mother is receiving treatment for a disease such as cancer during pregnancy when a delay in treatment can affect prognosis. In my view, this list should also include any condition that can deteriorate during and after pregnancy, for example, some heart conditions, pregnancy in children in whom continuing the pregnancy could pose high risks, as well as severe mental health problems caused or exacerbated by pregnancy that may lead to serious self-harm or even suicide.

Quoting Mallia, “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”.

And herein lie the problems. First, the doctrine refers to Catholic doctors and the assumption across this fair land of ours seems to be that all doctors are Catholic and all must therefore follow this doctrine. Nothing could be further from the truth. There are some 2,500 doctors on this island, some of whom were brought up in other faiths, and some of whom have no faith at all. Must non-Catholic doctors use a Catholic doctrine to decide on clinical management?

Second, although Prof. Mallia clearly expounds the four conditions for the application of this doctrine, the clinical difficulty lies in determining exactly when the risk to the mother becomes grave enough to warrant ending the pregnancy. We certainly do not want another unnecessary maternal death such as that of Savita in Ireland or Izabella in Poland. Doctors should not have to wait for the health of pregnant persons to deteriorate so badly that they are at the brink of death before medical action is taken. Here I would like to debunk the oft-quoted statement by the anti-choice brigade that since no mother has died in pregnancy in the past 10 years, we must be doing something right! Actually, maternal mortality statistics in Malta show that there was one maternal death in 2008 and another in 2010. So we have had two deaths in the past 14 years! Moreover, given that maternal mortality is reported per 100,000 births, and given that Malta has approximately 4,000 births per year, it would take some 25 years to expect even one maternal death. I hope we can all agree that using maternal death as a marker of good healthcare is a very, very low bar to set.

Third, there are absolutely no exceptions in the Maltese criminal law governing abortion. Any doctor, who chooses to apply the doctrine of double effect in their clinical practice, does so in breach of the law. This brings us neatly to the issue of medical induction of delivery (or abortion by any other name) before fetal viability. In this context, viability is defined as the ability of a fetus to survive outside the uterus, which in most western countries is generally accepted to be between 22 and 24 weeks. In the Prudente case, all amniotic fluid had drained away when her membranes ruptured at 16 weeks. Even if the pregnancy had continued, the lack of fluid would have seriously affected lung development and therefore the ability to breathe after birth. The fetus would have suffocated to death.

And finally, patients have rights too. They have the right to the protection of health and medical treatment that must be given without delay. In situations of non-viability when there is still a heartbeat, and when the pregnant person is at risk (as in the Prudente case), the rights of the pregnant person exceed those of the fetus. Quoting Mallia again, “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”. Here, I fully agree with Professor Mallia. The law must change to allow every pregnant person the right to choose what she deems best for herself.

 

Professor Isabel Stabile is writing on behalf of Doctors for Choice