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
Why bother about abortion?
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
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 yearnearly half of all
pregnancies in the Philippinesare 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):140149.
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?
Profile of Patients Who Have Abortions Is the Majority
Religious or Non-Religious?
Profile of Patients Who Have Abortions First-Timers or
Old-Timers?
Profile of Patients Who Have Abortions Formally Educated or
Not?
Profile of Patients Who Have 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.
Menstrual Cycle
Human Fetal Developmental Stages
CONCEPTION Fertilization Zygotes 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
Types of Abortion
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 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
Surgical Abortion
Medical Abortion (Early Pregnancy) Mifepristone plus
Misoprostol Mifepristone, 100600 mg orally, followed by:
Misoprostol, 400 g orally or 800 g vaginally in 672 hr Methotrexate
plus Misoprostol Methotrexate, 50 mg/m2 intramuscularly or orally,
followed by: Misoprostol, 800 g vaginally in 37 days; repeated if
needed 1 wk after methotrexate initially given
Medical Abortion (second trimester) Oxytocin in normal saline
solution
Medical Issues
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 womans life. Center for
Reproductive Rights, The Worlds 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 Center for
Reproductive Rights, The Worlds Abortion Laws(2009).
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 worlds population, permit abortion for any reason, though
most limit the period during which women can readily access the
procedure. Center for Reproductive Rights, The Worlds Abortion
Laws(2009).
Countries that permit abortion to save a mothers 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 womans age or capacity to
care for a Child Source: Center for Reproductive Rights, Worlds
Abortion Laws (2009). Abortion
Countries that permit abortion to protect mothers 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: 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 womans age or capacity to care for a Child
Source: Center for Reproductive Rights, Worlds Abortion Laws
(2009). Abortion
Countries that permit abortion to protect mothers life and
physical health, as well as mental health(in Asia) Israel R/I/F/+
Malaysia Thailand R/F 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
womans age or capacity to care for a Child Source: Center for
Reproductive Rights, Worlds Abortion Laws (2009). Abortion
Countries that permit abortion to protect mothers 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: 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
womans age or capacity to care for a Child Source: Center for
Reproductive Rights, Worlds Abortion Laws (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: 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
womans age or capacity to care for a Child Source: Center for
Reproductive Rights, Worlds Abortion Laws (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 Thomsons analogy Only covers cases of rape. The
violinist is not someone to whom one is related, even
potentially.
Jane Englishs 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
What to do?!?!
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
