Medical and bioethical issues in abortion

By Maria Theresa R. Termulo, M.D.
August 24, 2013
Medical and Bioethical Issues
in Abortion

 The Atheist Doctor
(http://theatheistdoc.ph)
 De La Salle University, Taft-
Manila (B.S. Biology)
 University of Santo Tomas
Faculty of Medicine and
Surgery
 Licensed Physician since
August 2005
 Victor R. Potenciano Medical
Center
 Internship (2004-2005)
 Internal Medicine Residency
Training (2008-2011)
 Emergency Room Officer
(May 2012 – present)
 Mandaluyong City Medical
Center
 In-house Internist (May
2012 – present)

 No particular
affiliations with any
pharmaceutical
companies
 No product
endorsements

OBJECTIVE
1. To impart medical knowledge about abortion, in
order for you to make an informed choice.
2. To create informed awareness on the reality of
abortion in the Philippines

INTRODUCTION
 Unintended pregnancy is common in the
Philippines, and it often leads to abortion
 Six in 10 Filipino women say they have
experienced an unintended pregnancy at some
point in their lives.
 About 1.43 million pregnancies each year—nearly
half of all pregnancies in the Philippines—are
unintended.

Nearly half of pregnancies each year end in an induced abortion or
an unplanned birth
Juarez F et al., The incidence of induced abortion in the
Philippines: current level and recent trends, International
Family Planning Perspectives, 2005, 31(3):140–149.

 In 2008, an estimated 560,000 abortions were performed
in the Philippines, and 1,000 women lost their lives to such
procedures while as many as 90,000 were hospitalized for
complications
 The Philippines has one of the highest maternal mortality
ratios in the Western Pacific Region, as defined by the
WHO, at 230 maternal deaths per 100,000 live births
.
Center For Reproductive Rights. FORSAKEN LIVES:
The Harmful Impact of the Philippine
Criminal Abortion Ban. 2010

Reasons Why Filipino Women
Attempt Abortion
 Inability to afford the economic cost of raising a
child
 Pregnancy resulted from forced sex
 They have enough children
 Pregnancy occurred too soon after the last one
 Feared pregnancy will put their health at risk
 Feared that their partners do not want the
pregnancy
 Older patients: they have too many children
 Younger patients: conflict with school; consider
themselves too young to have a baby
Singh S et al., Unintended Pregnancy and Induced
Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher
Institute, 2006.

Profile of Patients Who Have
Abortions
Is the Majority Married or Unmarried?

Abortions
Is the Majority Religious or Non-Religious?

Abortions
First-Timers or Old-Timers?

Abortions
Formally Educated or Not?

Abortions
Do They Use Modern Methods of Contraception Or
Traditional Methods?

Guttmacher Institute. In Brief: Meeting
Contraceptive Needs In the Philippines. 2009
series, No.1.

Majority of patients who have abortions are
POOR

Methods employed by Filipino
Women to attempt abortion
 Surgery or ―operation‖
 Dilatation and curettage
 Manual vacuum
aspiration (MVA)
 Misoprostol
 Hormonal pills
 Injectable hormonal
contraceptive
 Insertion of a catheter
into the cervix
 Insertion of other objects
into the cervix
 Massage
 Aspirin or other
medications
 Eating or drinking
traditional medicine/herbs
 Drinking alcohol
 Fasting
 Climbing a tree
 Jumping
 Exercising
Singh S et al., Unintended Pregnancy and
Induced Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher Institute, 2006.

Human Fetal Developmental
Stages

CONCEPTION
• Fertilization
• Zygote’s
genetic
makeup is
complete, incl
uding sex
• In about 5-10
days, dividing
very fast into
many cells
and
eventually will
pass through
fallopian tube
to attach to
the uterine
wall

4 Weeks
• Embryo starts
to form
structures
that will
eventually
become the
face and neck
• Heart, blood
vessels, lungs
, liver, stomac
h developing
• Home
pregnancy
test kits will
usually turn
positive

8 Weeks
• Half an inch
in size
• Eyelids and
ears forming
• Arms and
legs
• Fingers and
toes become
distinct
• Tissue forms
that develops
into the
vertebra and
some other
bones.
• Rudimentary
blood moves
through the
main vessels

12 Weeks
• 2 inches long
• Since Week
10 of
gestation, the
embryo is now
known as
―fetus‖
• Starts own
movements
• Fetal
heartbeat
(using
doppler)
• Intestines
rotate
• Genitals
appear well-
differentiated
• All essential
organs have

16 Weeks
• 4.3 to 4.6
inches long
• Heart and
blood vessels
are fully
formed
• Fingerprints
• Lanugo
• More muscle
tissue and
bones have
developed,
and the
bones
become
harder.

20 Weeks
• 6 inches long
• Top of the
uterus is at
the level of
the belly
button
• ―quickening‖
• suck
thumb, yawn,
stretch
• hearing
• Gender is
clearly seen
at ultrasound

24 Weeks
• Responds to
sounds by
moving or
increasing
pulse
• Lanugo hair
covers entire
body.
• Jerking
motions or
hiccups
• fetal
heartbeat can
be heard with
a stethoscope
• Bone marrow
begins to
make blood
cells

28 Weeks
• Baby weighs
2 pounds
• Lung maturity
begins (air
sacs)
• hand and
startle reflex
• nervous
system is
developed
enough to
control some
body
functions
• Rapid brain
development

36 Weeks
• Brain rapidly
developing
• Lungs fully
developed
• rapid increase
in the amount
of body fat
occurs
• Head
positioned
down in the
pelvis
• bones are
fully
developed, bu
t still soft and
pliable

Threatened Abortion
 a pregnancy is complicated by vaginal bleeding
before the 20th week.
 Pain may not be a prominent feature
 Vaginal examination at this stage usually reveals
a closed cervix
 25% to 50% of threatened abortion eventually
result in loss of the pregnancy.

Inevitable Abortion
 vaginal bleeding and cramp-like lower abdominal
pain.
 The cervix is frequently partially dilated, attesting
to the inevitability of the process

Incomplete Abortion
 vaginal bleeding, cramp-like pain, and cervical
dilatation with some passage of products of
conception

Complete Abortion
 passage of all the products of conception
 the uterine contractions and bleeding abate
 the cervix closes
 uterus is smaller than the period of amenorrhea
would suggest
 symptoms of pregnancy are no longer present
 the pregnancy test becomes negative

Missed Abortion
 fetus has died but is retained in the uterus

Etiologies
 Fetal Factors
 Maternal Factors
 Paternal Factors

Etiologies: Fetal Factors
 Abnormal zygotic development
 Chromosomal abnormalities

Etiologies: Maternal Factors
 Infections
 Chronic debilitating diseases
 Endocrine abnormalities (hypothyroidism, Diabetes
mellitus)
 Drugs
 Alcohol
 Caffeine (at least 5 cups of coffee per day exhibited a
slightly increased risk of abortion)
 Radiation
 Contraceptives
 Uterine defects
 Incompetent cervix

Etiologies: Paternal Factors
 Chromosomal abnormalities in sperm

Medical Abortion (Early
Pregnancy)
 Mifepristone plus Misoprostol
Mifepristone, 100–600 mg orally, followed by:
Misoprostol, 400 g orally or 800 g vaginally in 6–72
hr
 Methotrexate plus Misoprostol
Methotrexate, 50 mg/m2 intramuscularly or orally,
followed by:
Misoprostol, 800 g vaginally in 3–7 days; repeated
if needed 1 wk after methotrexate initially given

Medical Abortion (second trimester)
 Oxytocin in normal saline solution

Medical Issues
 When is it allowed to happen?
 Which takes precedence: Mother or Baby? Is
consent of partner required?
 Pregnancies as a result of rape
 Can abortion be offered to mentally-ill patients?
 Patients dying due to Septic Abortion
(unsuccessful/successful attempt at abortion)

When is it allowed to happen?
 Therapeutic abortion
 heart disease after cardiac decompensation
 advanced hypertensive vascular disease
 invasive carcinoma of the cervix

 Abortion is permitted in nearly every country at
least to save the life of the pregnant woman
(―Defense of necessity‖) - allows a doctor, for
example, to justify breaking the law by performing
an abortion because the action saved a woman’s
life.
Center for Reproductive Rights, The World’s Abortion Laws(2009).

 Nearly half of all countries permit abortion in
cases of rape or incest, in addition to other
grounds, though procedural requirements in
these cases may vary.
 Many of the same countries permit abortion in
cases of fetal impairment

 More than one-third of all countries allow abortion
on economic or social grounds, such as income
level, age, marital status, and number of children.
 More than 50 countries, with nearly 40 percent of
the world’s population, permit abortion for any
reason, though most limit the period during which
women can readily access the procedure.

Countries that permit abortion to
save a mother’s life (in Asia)
 Afghanista
n
 Banglades
h
 Bhutan –
R/I/+
 Indonesia
 Iran – F
 Iraq
 Laos
 Lebanon
 Myanmar
 Oman
 Philippines
 Sri Lanka
 Syria
 United
Arab
Emirates –
SA/PA
 West Bank
&
 Gaza Strip
 Yemen
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion

Countries that permit abortion to
protect mother’s life and health(in
Asia)
 Jordan
 Kuwait –
SA/PA/F
 Maldives –
SA
 Pakistan
 Qatar – F
 South
Korea –
SA/R/I/F
 Saudi
Arabia –
SA/PA
Note:
incest
impairment
required
U – Law unclear
to care for a
Child
(2009).
Abortion

Countries that permit abortion to protect
mother’s life and physical health, as well as
mental health(in Asia)
 Israel –
R/I/F/+
 Malaysia
 Thailand –
R/F
Note:
incest
impairment
required
U – Law unclear
to care for a
Child
(2009).
Abortion

Countries that permit abortion to protect
mother’s life and physical health, as well as
mental health and based on socio-economic
background(in Asia)
 India –
PA/R/F
 Japan –
SA
 Taiwan –
SA/PA/I/F
Note:
incest
impairment
required
U – Law unclear
to care for a
Child
(2009).
Abortion

Countries that permit abortion without restriction
as to reason (during first trimester)
 Armenia
 Azerbaijan
 Bahrain
 Cambodia –
 GL 14 weeks
 China – S/GL-
none
 North Korea –
GL-none
 Georgia – PA
 Kazakhstan
 Kyrgyzstan
 Mongolia
 Nepal – S
 Singapore –
 GL 24 weeks
 Tajikistan
 Turkey –
SA/PA/GL
10 weeks
 Turkmenistan
 Uzbekistan
 Vietnam –
GL-none
Note:
incest
impairment
required
U – Law unclear
to care for a
Child
(2009).
Abortion

Bioethical Issues
 Moral status of a fetus
 Is the fetus a person? At what stage in its
development does it becomes a person?
 Rights of the Pregnant Patient
 Does the pregnant woman have the right to decide
if she is going to carry the baby to term or not?
 Principle of Double Effect

Bioethical Issues
Is a fetus a person?

Possible Criteria of Personhood
 Conceived by humans
 Genetic structure
 Physical resemblance
 Presence of a soul
 Viability

Judith Jarvis Thomson and Jane
English
―Even if the fetus is a person, abortion may be
morally justified‖

Limitations of Thomson’s analogy
 Only covers cases of rape.
 The violinist is not someone to whom one is
related, even potentially.

Jane English’s Revisions
 Imagine that you go out at night, knowing that you
might be rendered unconscious and hooked up to
the violinist.
 You would still, according to English, be entitled
to unhook
yourself.
 This case is more closely analogous to
conventional cases of unwanted pregnancies.

Principle of Double Effect
 Four Conditions must be met:
 the action itself must be either morally good or at
least morally neutral (nature-of-the-act condition);
 the bad consequences must not be intended (right-
intention condition);
 the good consequences cannot be the direct causal
result of the bad consequences (means-end
condition);
 the good consequences must be proportionate to
the bad consequences (proportionality condition).

Personal and Professional
Experience Related to Abortion

Personal and Professional
Experience Related to Abortion
 As a Medical Clerk and Intern
 In UST
 Some OB-Gyne Residents scolding patients, threatening
report of incident to the police
 OB-Pedia projects: Mothers’ classes
 In Fabella
 Patients treated a little more kindly but still with some
instances of ―rudeness‖ from health-care staff
 OB doctors educating mothers
 In VRP

Six in 10 of a small sample of providers interviewed
in 1999 reported that although they believe women
who have had abortions should receive medical
attention, the women ―are criminals and should be
punished.‖
Tandigan E et al., Assessing Health Workers’ Attitudes and Practices on Abortion
in Selected Health Facilities in the Province of Nueva Vizcaya, Manila, Philippines:
EngenderHealth and United Nations Population Fund, 1999

 Inform loved ones/people you trust most
 SEEK PHYSICIAN CONSULT PERSONALLY
 If you attempted abortion, STILL SEEK HELP!

References/Recommended
Readings
 Center For Reproductive Rights. FORSAKEN LIVES:
The Harmful Impact of the Philippine Criminal
Abortion Ban. 2010.
 Singh S et al., Unintended Pregnancy and Induced
Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher
Institute, 2006.
 Judith Jarvis Thomson, "Abortion," The Boston
Review, Vol. XX, No. 3, (Jan 1994/Dec 1995). Full text
& replies.
 Fetal Development Picture Slideshow. WebMD.
http://www.webmd.com/baby/ss/slideshow-fetal-
development.
 Fetal Development. Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/0023

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