Directing change

John Turnbull was surprised by the recent media interest in an apparent abortions crisis and the possibility that they may become increasingly rare not on immediate moral grounds but because of the Working Time Directive

A woman's right to choose an abortion has, since the legislation of 1967, led to a growing number of such terminations in this country. This 'right', like so many others enshrined in law, was based on an assumption that it could be fulfilled. In other words, if the law permitted an abortion, then there would be a doctor and a clinic that to carry it out. All this appears to be changing.

Britain is facing an 'abortions crisis' because an unprecedented number of doctors are refusing to be involved in carrying out the procedure. The exodus of doctors prepared to perform the task is occurring across the UK and threatens to escalate further.

The Royal College of Obstetricians and Gynaecologists [RCOG] was forced to issue a public statement after a headline-grabbing article by Jeremy Laurance in The Independent last April. 'The RCOG recognizes that abortion is an essential part of women's healthcare services and adequate investment and workforce is essential, and is aware of the slow but growing problem of trainees opting out of training in the termination of pregnancy and is therefore concerned about the abortion service of the future.

'The RCOG recognizes that it is an important right for any doctor to object to performing abortion. The future of the sexual healthcare services requires careful workforce planning in order for abortion services to be available to the women who need it most. Most woman find the decision to go forward for termination very difficult and it is essential that there is a trained and sympathetic workforce to help in this aspect of woman's health.

Growing demand

'The RCOG also believes that proper education and use of contraceptives are essential to prevent unwanted pregnancies and sexually transmitted infections. Likewise, it is crucial that our family planning and gynaecological services have the suitable investment and funding needed to offer an appropriate service.

More than 190,000 abortions are carried out each year in England and Wales and the health service is currently struggling to keep up. The reluctance of NHS staff, both doctors and nurses, to be

involved has led to a doubling of abortions, paid for by the NHS, which are carried out in the private sector, from 20% of the total in 1997 to almost 40% a decade later.

Distaste at performing terminations, combined with ethical and religious convictions that do not appear to have lessened even after forty years of liberalism and secularization, has led to a big increase in conscientious objectors who request exemption. A key factor, apparently, is what is called 'the dinner party test'. As one commentator put it, 'Gynaecologists who specialize in fertility treatment, creating babies for childless couples, are almost universally revered, but no one boasts of being an abortionist.'

Who would have thought it? It started from the European Working Time Directive, accepted in law in the UK in 1998. Which in turn led to the government's attempt to limit the working hours of junior doctors in particular. These changes to junior doctors' terms and conditions, finally introduced two years ago, mean that they can now choose which areas of medicine to train in - and increasingly few are opting to carry out abortions.

The Guardian argued, therefore, that the problem was caused by the growing numbers of 'intolerant' doctors who believe women seek terminations because they are too lazy to use contraception. As Ann Furedi, chief executive of the British Pregnancy Advisory Service said, 'Many young doctors are unwilling to provide terminations because they believe there is no good excuse for unwanted pregnancies. Younger doctors can be judgemental. They do not see why they should have to, as one put it to me, clear up the mess if women cannot be bothered to use contraception.

'There is a real crisis looming. Unless we can address the problem and motivate doctors to train in abortion, we may well face a situation in five years' time in which women's access to abortion is severely restricted. It is our biggest headache.'

Richard Warren, honorary secretary of the RCOG and a consultant obstetrician in Norfolk, commented, 'In the past, abortion was an accepted part of the workload. People did not like it but they accepted that it was in the best interests of the woman concerned. Now people are given the option of opting out of the bits of the job they don't like doing and if two or three say 'No thanks,' it makes it easier for others to follow.'

Conflicting experience

James Gerrard, a GP in Leeds, refuses to refer any of his patients seeking the operation. During his training in the Nineties he also opted out of any tuition on abortion. 'Medically, abortion really is not a popular thing to do. It is not a very technical or demanding operation and it's actually quite disheartening. There are no handshakes or slaps on the backs afterwards, nor the sense that you've done something great for someone. The best you can hope for is the sense of relief that it is over.

'In my day to day work I deal with requests for terminations but I have a conscientious objection to that. During the consultation I will tell them because of my personal views I cannot refer them to hospital for the procedure and they will have to speak with another doctor. I had made my mind up on abortion before entering the medical profession. I am a Roman Catholic and my religious beliefs do form my moral point of view. Personally I feel the foetus is a person, and killing that foetus is wrong. I have not come up against any aggression because of my stance, either from colleagues or from patients I've refused to refer. I think people understand it is a personal choice and respect that.'

Kate Guthrie, who performs terminations regularly, is aware that it is not a comfortable career choice. 'In a social environment people can go cold on you. Others are really interested. But the worst are colleagues - they can be overtly rude. Most young doctors now are middle class and have no experience of what life is like on inner-city housing estates. Their working hours have been cut. They don't get the breadth of clinical experience they once had, so they pick and choose the sexy bits of the job.'

Has this meant that, after decades of campaigning, those seeking to restrict the law on abortion will succeed as it were by default? \ND\

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