Imagine you are a GP, about to call in your next patient, Belinda. She is pregnant. A routine anomaly scan had suggested a minor degree of unilateral club foot, confirmed on a more detailed scan at 23 weeks reported by a radiologist and paediatric orthopaedic surgeon.

Talipes Equinovarus (also known as club foot) affects about 1 in 100 live births. Many cases are 'positional', and require only physiotherapy. Cases diagnosed antenatally are more often 'fixed' and more complex, but not all of these require surgical treatment. A combination of splinting and physiotherapy is often sufficient.

Belinda requests referral for abortion, which she had also considered after the first scan. Then she had reluctantly continued with the pregnancy because her partner Tom was keen to continue. They've had several arguments about this, but Belinda felt she couldn't handle having a deformed child. Specialists have already explained to her that they cannot be certain of the severity or persistence of the deformity, and, indeed, if any treatment will be needed at all until the child is born and fully assessed.

You further discuss with Belinda the usual treatment of simple manipulation techniques. However, she is still very concerned, and is finding it difficult to come to terms with the idea that her child may be 'deformed' in any way. You then ask yourself, as a virtuous doctor (see below), should you refer Belinda for a termination of pregnancy?

what is a virtuous doctor?

Virtue theory was derived mainly from Aristotle's work, but is increasingly being recognised in medical practice as limitations of other duty based or consequence based theories are being recognised. Virtues are character traits that dispose their possessor habitually to excellence of intent and performance with respect to a particular activity.

Healing and preservation of human life are specific to medicine and therefore qualities which increase the capacity to heal well are virtues of medicine – prudence, benevolence, being compassionate and caring. A virtuous doctor would be one who possesses these character traits.

abortion law

In the UK, the Abortion Act 1967 (amended by the Human Fertilisation and Embryology Act 1990) outlines the criteria under which abortion is legal. The four statutory grounds are expressed as grounds A-E on the HSA1 form/Certificate A. (1) Two registered practitioners must be satisfied that one of them is met in order to make a bona fide decision, an opinion formed in good faith. The criteria allow for abortion in cases of 'serious handicap' at any stage of pregnancy.

At this point would you sign the referral form or not? Are there sufficient legal grounds?

virtues in the Bible

Building character is central to our growth as Christians, and God often does this work in us by testing our faith through challenging situations. (2) We are encouraged to ask for virtues like wisdom (3) and to add them to our faith so that we will be fruitful in our work and knowledge of Christ. (4)

Though the importance of virtue is increasingly being recognised in medical practice, a secular understanding of virtue may differ from a Christian one. Virtues are not necessarily the same as the 'fruit of the spirit'.(5) By analysing Belinda's case, we will look at how thinking about virtues and the patient's story broadly may help us come to wiser or more morally acceptable decisions in healthcare. The Narrative Virtue Theory may reflect some Christian values but we will also see how the two are not exactly the same.

Belinda's narrative and analysis

'Hello. My name is Belinda and I am a 37yr old actress and dancer. I was happily expecting my first child until a week ago. After my anomaly scan, they told me my child has a club foot. My child will be deformed and will have problems with mobility. I am concerned and am finding it very hard to accept that, not really sure why. They have confirmed it today and I want an abortion.'

Assuming a planned and spontaneous conception, why might Belinda want an abortion?

1. Concern about the future welfare of the child and how he/she will fit into society

2. Her dreams for the child might have been shattered by the deformity

3. She may be finding it difficult to accept her child would be disabled in any way

4. She could be worried about the future of her career and have changed her mind about starting a family

Based on these possible reasons you now ask yourself whether there are sufficient legal and moral grounds to refer Belinda for an abortion. Is Belinda's decision to terminate pregnancy a virtuous one? If we saw reasons 1 and 4 above as good and necessary to achieve a more flourishing life, we could say Belinda is displaying virtues of strength, courage, decisiveness and responsibility. We may have a duty to 'respect her autonomy' and allow her to exercise her choice to have a termination. So some would see having an abortion for the reasons listed above as a virtuous thing to do.

We might agree that abortion is not really comparable to having a haircut or appendicectomy, and admit that cutting off a human life connects with all our thoughts about human life and death, parenthood and family relationships and is therefore an important matter. We can question whether Belinda has the right attitude about the seriousness of loss of life, especially when that life is being taken for a medical condition that can be effectively managed or even cured. If Belinda's decision is based on reasons 2 and 3 we could argue that her decision to abort in this case could indeed be callous; selfish, light-minded, inconsiderate and disloyal. The list could go on.

Tom's narrative and analysis

'Hi, I am Tom, Belinda's partner and I love her. I was so thrilled when she got pregnant and was looking forward to being a dad. The thought that she now wants to abort our child because he/she may be slightly deformed is stressing me. When I was younger I had testicular cancer which left me with reduced fertility and this could be my only chance to be a dad. Being the only child my parents would be so happy if I had a child who could carry on the family business.'

There seems to be a different voice from Tom's story. A narrative based approach developed by Margaret Walker (6) identified that moral values do not come from value-free contexts but from continual negotiation among people. There is mutual allotting, assuming and deflecting of important responsibilities in life under three domains; narratives of value, relationship and identity. Tom holds important values of family life, care and love for Belinda (assuming he wants a child with her only because of their love). He may also regard having a child as important to his identity as a father, long-term partner and member of society. His relationship with family, Belinda and child would therefore be more important than concern over a deformity which can be effectively treated. Being in a long term relationship and having planned the pregnancy, we would understand Tom's expectation that Belinda would carry the baby to term to have a child that they will love and accept for whom he/she is. With the history of cancer and reduced fertility, this could also be Tom's only chance to have an heir.

How has hearing the narratives affected your initial decision? Which story offers a greater moral weight to the decision?

disability and discrimination

Another important consideration is Belinda's and our society's attitude towards disability. It is difficult to define disability but a useful way to look at it is viewing disability as functional limitation (on its own or more commonly with a social disadvantage) which impairs the capacity for human flourishing.7 But this definition begs the question, what is a flourishing human life? For Belinda it could be success in her career, but would her child necessarily want to pursue the same path or flourish in other ways which may not need perfect feet or legs? The list of professions or other valuable jobs the child could do is endless. Is Belinda displaying mere perfectionism which is out of touch with the reality of life and what makes life a fulfilling or happy one for us as humans?

If she has no real reason why she cannot accept her child with any deformity, even if it can be cured, isn't this really a reflection of stigmatising attitudes or discrimination towards the disabled? If as a society we accept such a disability as the sole reason to kill a foetus then the message we communicate to those who are disabled may not be a virtuous one. Surely, true virtue towards the disabled would be a commitment to care and love them as they are, helping them to live with a quality of life as good as is possible.

Some secular scholars like John Harris however spread a wide net by defining disability as 'a condition that someone has a strong rational preference not to be in…a harmful condition relative not to normal functioning but to possible alternatives'. (8) This view would therefore support Belinda to abort if she would rather not be a mother of a disabled child. The Abortion Act does not specify what 'substantial risk' or 'serious handicap' means but guidelines from the Royal College of Obstetricians and Gynaecologists9 encourage doctors to use their discretion, involving the parents in the decision and especially the views and choices of the mother.

reaching a decision

A final decision could be made by asking yourself which narrative (Belinda's or Tom's) affected or convinced you the most in order to decide whether referring for termination would be a virtuous course of action to take or not. Exploring their desires, intentions, character and relationship to the child and each other enriched our moral reasoning although it may not be prescriptive enough to guide any specific action. If you refuse to refer her for the termination, she is entitled to be informed that she can see another doctor10 who may support her decision or have no conscientious objection to abortion in such a situation.

Virtue ethics may prove helpful in thinking through answers. But without the measuring stick of God's word to determine what is virtuous, some could view Belinda's decision to abort as virtuous, and most would see this as inconsistent with the biblical value of life; that in spite of its flaws, life is a gift from God and is to be celebrated and protected.

Since the fruit of the Spirit consists of much which we would consider virtuous, it can be easy to assume virtue ethics to be very similar to Christian ethics. Analysis of this case has shown that this isn't always true. Looking at different ethical systems can help us think through problems, but can lead to some difficult conclusions without God's Word to guide us.

The truth is that no secular ethical theory alone is likely to be an adequate reflection of how a Christian should make a decision. Christian ethics include elements of many different models, but ultimately we should remember when we make decisions as Christians we are not primarily using secular theories of ethics, but instead obeying God. It should not surprise us that God's commands do not fit neatly into the categories the world would try to impose.