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Medical and bioethical issues in abortion

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a primer on the medical and bioethical issues in abortion, with some statistical information based in the Philippine setting.

Text of 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
  • 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 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
  • 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
  • Thank You!