implications of new in utero surgery for fetuses with spina bifida

In October 2018, in utero spinal surgery was performed in the UK for the first time on two fetuses with spina bifida. (1) In February, the Secretary of State for Health and Social Care, Matt Hancock confirmed that the procedure will be available on the NHS and take place between 20 and 26 weeks gestation. Anaesthesia will be administered to the fetus prior to surgery. (2)

Currently, the age at which a fetus is considered susceptible to pain is 20 weeks, though some studies indicate pain is felt from 15 weeks. This raises uncomfortable questions about the level of pain experienced by unborn babies aborted after 15 weeks.

Statistics for 2017 (3) indicate that 197,533 abortions were carried out in England and Wales. The majority were carried out on fetuses at less than 13 weeks gestation (9 out of 10) and four out of five at less than ten weeks. There were 252 abortions of fetuses 24 weeks or over (0.1% of the total).

Most abortions (66%) are carried out medically using an abortifacient drug like mifepristone. The remainder are carried out surgically, either by vacuum aspiration (up to 15 weeks) or dilatation and evacuation (over 15 weeks) - the stage at which the fetus may be presumed to experience at least some level of pain.

Feticide, before abortion, is recommended by the RCOG in cases where the unborn baby is 22 weeks or more and involves stopping the heart either by lethal injection or as part of the procedure. This recommendation was apparently followed in 96% of cases, but it can take several hours for the fetus to die. (4)

There is currently a disconnect between the treatment of fetuses destined for life and those destined for death, though their capacity for suffering is equivalent. Might this lead society to question our attitude toward the way in which late-term abortions are carried out, or even whether they should be carried out at all?

'abortion as a moral good'?

An article by Katie Porter published by The Lancet on 23 March 2019 (5) describes a debate between two 'Christians' - one a pro-life family physician and the other an obstetrician involved in abortion care. The writer is encouraged by the fact that the debate is amicable, and the protagonists respect each other's commitment to patient care.

As a bioethicist, Porter is troubled by the fact that medical ethics has become a 'largely secular enterprise in the USA'. When abortion was illegal, there were Christians who spoke against the injustice of making it a criminal offence. But how since its legalisation, those who oppose it are largely doing so on moral and religious grounds - thinking of the fetus and its right to life rather than the woman and her right to 'choice'. Consequently, Porter believes the debate has become polarised, with people on opposite sides of the abortion debate 'talking past each other'.

Her solution is to correct the 'false assumption' that only pro-lifers are thinking ethically. However, as she unpacks her argument that being pro-choice is equally 'moral', the irreconcilable differences in world view and underpinning attitudes toward abortion becomes apparent. The debate is pushed no further forward.

abortion and mental illness

Research around the negative emotional and mental health consequences of abortion is ambivalent as it must consider many factors and is sometimes influenced by bias. To be significant, it must be compared to similar negative consequences attending an unwanted pregnancy carried to full term, and the guilt a mother might feel if she gives up her baby for adoption.

In a paper describing the results of a 30-year longitudinal study, Prof David Fergusson et al (6) (with apparently no axe to grind) found that 'women who had had abortions had rates of mental health problems that were about 30% higher than rates of disorder in other women.' However, the research suggests that some of these conditions, eg. anxiety and substance use disorders were pre-existing (ie. not a result of their experience of abortion) and that 1.5 - 5.5% of the 30% were directly attributable to their experience of abortion.

It is worth noting that 'none of the other pregnancy outcomes (pregnancy loss, live birth following unwanted pregnancy or a pregnancy having an initial adverse reaction, and other live birth) was consistently related to significantly increased risks of mental health problems.'

Not all research agrees with Fergusson's conclusion, (7) but this ambiguity surely means that the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual and Reproductive Healthcare (FSRH) are not justified in confidently declaring in a factsheet for schools (8) that 'abortion does not cause mental illness.'

RCP officially neutral about assisted suicide

The Royal College of Physicians (RCP) has traditionally been opposed to the legalisation of assisted suicide, but in response to pressure from a vocal minority opposed to its stance, it carried out a poll of its members earlier this year. Instead of giving members a clear choice between two options (to legalise or not to legalise), the RCP required a 60% majority for the two main options and introduced a third - that of neutrality around the issue, thus making it much more difficult to get a clear majority for any one of these options. (9)

In the event, 43.4% voted to maintain opposition - with 25% voting to go neutral. As a result, the RCP has decided that as of 21 March 2019, it will no longer oppose the legalisation of assisted suicide.

Four doctors, two of whom are CMF members, are taking the RCP to court over this decision, and would welcome your support (visit www.gofundme.com/rcp-poll-challenge for details).

the world's first malaria vaccine

Half of the world's population are at risk of malaria with sub-Saharan Africa carrying most of the global burden of disease (90% of all cases and 92% of all deaths). According to 2017 data, 61% of the world's 435 000 annual malaria deaths occur in children under five-years-old. (10)

A new tool in the fight against malaria is being clinically tested in young children across three African countries: Malawi, Ghana and Kenya. RTS,S/AS01(RTS,S) has been in development for three decades and is a first generation vaccine against the most deadliest malaria parasite - plasmodium falciparum, (11) which is responsible for 99.7% of cases within the WHO African region. (12) It provides partial protection against malaria and there are hopes that it will be used as a complementary tool to existing measures such as insecticidal nets, prompt diagnostic testing and treatment of confirmed cases with antimalarial medicines. (13)

At Phase Three trials, RTS,S produced promising results. Children who received four doses, experienced significant reductions in malaria and malaria related complications. (14) The trials hope to answer questions about feasibility: vaccination delivery its role in reducing childhood deaths and vaccine safety. The hopes are that 360,000 children per year will be reached in selected areas, with data reporting as early as 2022. (15)

harassment in healthcare

The BMA has launched an enquiry into sexism and sexual harassment. Senior female GPs have exposed a culture of 'institutional sexism' (16) within the BMA's GP Committee, reporting belittling, crude and sexist comments, being ignored or frozen out of meetings and sexual harassment. Drawing upon examples of best practice, the independent investigation (17) will review the allegations and make recommendations to address gender bias and harassment in the BMA. The profession is following calls in many areas of public life to reform its treatment of women. Let's lead by example as Christians and consider how we can live out the Bible's teaching that 'Do not rebuke an older man harshly, but exhort him as if he were your father. Treat younger men as brothers, older women as mothers, and younger women as sisters, with absolute purity.' (1 Timothy 5:1-2)

doctors blame themselves for mental health problems

A survey of UK doctors found that most doctors (80%) were at a high or very high risk of burnout, with junior doctors most at risk. (18) Researchers from Swansea University asked doctors in training from a range of specialties about whether being a doctor had affected how they accessed support for mental health problems. The survey revealed a prevailing view that 'mental illness is equal to weakness' and that some doctors continued to work even when their illness impaired their ability to do so.

The researchers suggested that one way to tackle stigma was for NHS employers to include information about the prevalence of illness among doctors at induction sessions.

This follows a large BMA survey, open to all UK doctors, which received more than 4,300 responses, including around 1,400 from medical students. More than a quarter (27%) of respondents reported having been given a diagnosis of a mental health condition at some point and that 40% currently had a psychological or emotional condition. This is similar to the prevalence in the general population and shows that healthcare workers and students are not immune to mental illness. Let's remind ourselves of Jesus' attitude to the 'harassed and helpless' crowds he met. He didn't denounce them for weakness, instead he had compassion on them (Matthew 9:36).