For most women, deciding whether or not to have an abortion is one of the most emotionally traumatic events in their lives, and opinions on the subject are sharply divided between so-called pro-choice and pro-life factions. Consequently it is hard to discuss abortion without provoking strong emotions and no short review of the subject will ever manage to present all viewpoints. But as abortion is so frequent within our society, the social and spiritual implications of it need to be constantly reviewed and discussed. This brief overview is written from a Christian perspective.

Western society is full of contradictions as can be seen in attitudes towards early human life. First, the healthcare system has departments of fetal medicine, while also providing facilities and staff to perform abortions. Secondly, the law allows abortion for abnormalities right up to term, but many babies born after only 23 weeks of pregnancy now survive having been looked after in neonatal intensive care units.

Thirdly, we encourage people to consider adoption, but abortion is so widely accepted and available that there are few babies to adopt. Fourthly we pass equal opportunity laws but work hard to ensure that babies with disabilities are screened out before birth.

Finally, at the same time as we are reducing the status of life before birth, medical technology is literally changing our view of the fetus. Antenatal genetic screening, three dimensional ultrasound pictures of babies in the womb and intensive care of premature babies have all had an influence on the way we think of the beginning of human life.

These contradictions are set against the reality that more abortions are carried out in England and Wales than ever before. In 2001 there were 176,364 abortions, involving 1.7% of the countries' women (about one for every four live births), an increase of at least 722 over any previous year.(1) Estimates suggest that 55 million abortions occur each year around the world.(2)

Other than the degree of social acceptability, there is nothing particularly new about abortion, although developments in medical science now mean that the procedure is much less risky for the woman.

In early pregnancy an abortion can be induced with drugs that interrupt placental function and cause a mis-carriage (ie mifepristone (RU486) then a prostaglandin). The more traditional surgical methods include vacuum aspiration or 'suction'. This is done under either local or general anaesthetic and the fetus and placenta are removed by a mixture of sucking and scraping the lining of the womb.

Once the fetus is larger than twelve to 14 weeks the surgical method becomes more obviously destructive. 'Dilatation and evacuation' involves general anaesthesia and piecemeal removal of fetal parts. Later still the fetus is killed in the womb by injection, and labour induced using prostaglandin drugs.

This paper recognises the distress of those with unwanted or abnormal pregnancies, but argues that the current permissive attitude towards abortion has led to an unprecedented loss of human life, and that abortion also damages society, and carries a risk of harming the women involved.

Autonomy arguments

Having respect for people's free will and their right to self-determination lies at the heart of many discussions about abortion. This interest in 'autonomy' is complex, however, because of the different parties involved.

There is the call for each woman to make decisions about what happens to her body - no one should force her either to carry or terminate a pregnancy against her will. On the other hand, there is the issue of the fetus' life, which raises the question of whether one person's desire for autonomy can extend to ending another's existence.

Then again there is the doctor who is asked to become part of this process. Should anyone be able to force a member of the medical profession to perform a task that they disagree with?

Currently the assumption in law is that the woman's need for autonomy overrules all else. After all, in England, Wales and Scotland human beings have no standing in law before birth, so their wishes cannot be taken into account. The Abortion Act 1967, however, does recognise the doctor's need for autonomy, making clear that members of the medical profession can opt out of being involved if they so wish.

Biblical input

The Bible does not mention abortion directly but it does comment on many issues that abortion raises.

To start with, the Bible says that procreation (sexual intercourse that results in the creation of children) should occur within married heterosexual relationships. About 82% of abortions result from sexual activity outside a marriage relationship.

Although Christians differ about the status of the early embryo, many believe that embryos should be shown great respect from fertilisation on the basis that a new unique human life begins at this point. However, debates about early embryos have little impact on abortion because most abortions occur after eight or more weeks of pregnancy, a time when all of a fetus' organs are in place.

Christianity teaches the highest regard for human life, and claims that the unique status of human life rests on the fact that we are made 'in God's image'.(3) While the precise meaning of this phrase is complex, it implies a special relationship with God; it is God's ability to relate to us, rather than ours to relate to him that gives us our value.

In addition, central to the Christian faith is the belief that Jesus Christ was not only human, but also God. The fact that God chose to live on earth as a human being, and began that life as an embryo, further enhances our appreciation of the value of early life.

Psalm 139 (4) emphasises God's continuity of care, saying that this reaches back into the womb, and that God was concerned for the individual while his body was being formed. The Bible gives examples of this process in action as can be seen when God 'called' Isaiah and Jeremiah and John the Baptist before they were born.(5)

The Bible has a strong prohibition against killing human beings because of God's special regard for us.(6) The exceptions to this are in various cases of self-defence.(7) This allows abortion in cases such as an ectopic pregnancy, where the woman's life is threatened by the fetus being present in the wrong place. Self-defence, however, must always be proportional to the threat.

At the heart of biblical morality is the idea that the strong should make sacrifices for the weak. We are called to 'bear one another's burdens', as Christians believe Jesus did for us.(8) This means not only providing fetuses with the utmost respect, but also helping mothers find compassionate and better alternatives to abortion; actions that may involve keeping her baby or giving him or her up for adoption. The Bible has a very positive view of adoption - indeed those who follow Christ are 'adopted into his family'.(9)

Pregnancy crisis centres such as those run by CARE Centres Network (10) and LIFE (11) are one practical expression of this approach. These provide free pregnancy tests, counselling and sup-port for women making decisions about abortion. They can refer women for antenatal care and adoption advice as well as providing financial and practical help during pregnancy. Importantly, the centres also offer support and counsel-ling for those who have had abortions.

Ethics and law

In the pre-Christian Western world there were two differing approaches to life and abortion. The Jewish world, informed by the Torah (the first five books of the Old Testament) had a high regard for human life at all stages and abortion was forbidden. In contrast Greek and Roman cultures generally approved of abortion for much the same reasons as our society does today. However, it was the Greek physician Hippocrates who, in contrast to this, developed a high regard for all human life as a basic principle of a doctor's work.

In the Christian era the Hippocratic Oath, which forbade any involvement in abortion, became central to the practice of medicine as it accorded well with biblical teaching. However, in the last 50 years, this prohibition has been gradually eroded, to the point that the Royal College of Obstetricians and Gyn-aecologists (RCOG) now sees abortion as a basic healthcare need (see box).

Changing ethical approaches to abortion

• I will not give to a woman a pessary to produce abortion. Hippocratic Oath
• I will maintain the utmost respect for human life from the time of conception even against threat. The Declaration of Geneva (1948)
• The spirit of the Hippocratic Oath can be affirmed by the profession. It enjoins... the duty of caring, the greatest crime being the co-operation in the destruction of life by murder, suicide and abortion. BMA statement 1947
• The child deserves 'legal protection before as well as after birth'. The UN declaration of the rights of the child 1959
• Therapeutic abortion (may be performed in circumstances) where the vital interests of the mother conflict with those of the unborn child. Declaration of Oslo 1970
• I will maintain the utmost respect for human life from its beginning... Amended declaration of Geneva 1983
• Abortion is a basic health care need. RCOG 2000

The Abortion Act 1967 came into effect on 27 April, 1968. This permits abortion in Great Britian (not including Northern Ireland) by registered practitioners subject to certain conditions. Section 37 of the Human Fertilisation and Embryology Act, 1990, made some changes to the legislation. This latter Act says that abortions can only be performed under grounds C & D before 24 weeks, but can be performed at any stage of fetal development for grounds A, B and E. Over 98% are performed under grounds C and D.

Grounds for permitting abortions under the current UK legislation

A - the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated

B - the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

C - the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman,

D - the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, or injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman,

E - there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Or in emergency, certified by the operating practitioner as immediately necessary:

F to save the life of the pregnant woman

G - to prevent grave permanent injury to the physical or mental health of the pregnant woman.

The Abortion Act is unusual in its provision of a 'conscience clause'. By giving doctors the ability to opt out of their involvement in the procedure it acknowledges the deep division of views within the medical profession. In practice, however, it means that it is very difficult for individual members of the medical profession to practise in obstetrics and gynaecology if they are not prepared to be involved in abortions.

Safety issues

Abortion has complications, many of which are not well publicised.

Death and illness

Less than 1 in 100,000 women die of early terminations, a figure that is lower than the 7.6 per 100,000 women who die in childbirth. Complications do, however, occur. These include damage and/or infection to the uterus and the Fallopian tubes making a woman infertile. Menstrual disturbances can also occur.

There is a problem associated with knowing the true numbers of women who suffer complications. The data collected is linked to a termination if the patient reports a problem within 14 days of the procedure. Most occur after this time and so are not linked when statistics are produced. (12)

Emotional trauma

Most abortions are carried out on the grounds of safeguarding the woman's mental health, but there is evidence that many women suffer significant emotional trauma after having an abortion.

One study found that 1.84 out of 1,000 women who had abortions were later admitted to hospital for psychiatric reasons, as opposed to 1.2 per 1,000 women who had declined an abortion and delivered their babies. (13) The risk was particularly high for women who were young, had previous pregnancies, had previous histories of mental illness, or were uncertain about whether or not they wanted an abortion. Those who came from social or religious backgrounds where abortion was disapproved of, or who aborted a fetus because tests showed a physical or genetic abnormality, were also more likely to be affected. (14)

Although there has been little research, many counsellors believe that the psychological trauma of abortion can re-emerge many years after the event, can affect men as well as women and has some features in common with post-traumatic stress disorder.

Breast cancer

There is also some evidence that having an abortion may increase a woman's risk of breast cancer in later life. The theory is that pregnancy stimulates growth and differentiation of breast cells, but suddenly stopping this procedure mid-way increases the population of cancer prone cells, thereby increasing the risk of tumours beginning to form. (15)

A 1997 review that pooled 23 studies found that the risk increased by 30%. (16) By contrast a 2001 review of evidence concluded that there was 'insufficient evidence to justify warning women of the future breast cancer risk when counselling them about abortion'. (17) One problem with making sense of any data associated with abortion is that it is prone to bias and inaccuracy because people so frequently do not tell the truth when asked questions about their past.

This is obviously a controversial area with vested interests on both sides, showing the need for better research and that doctors need to be aware of the arguments in order to give properly informed consent.

Demographic effects

When considering risks, one should not ignore the overall risk to society. Not only does a permissive attitude to abortion devalue our appreciation of fellow human beings, but it also runs the risk of changing the demographic make up of our communities.

When combined with other forms of birth control, abortion has led, especially in Eastern European and former Soviet Union countries, to a situation in which there are too few young and active people to care for the growing population of elderly. A net outcome of this could then be increased pressure for liberalisation of euthanasia.

Some of these countries, which formerly carried out more abortions than there were live births, are now tightening up their abortion laws out of concern for the future stability of their societies.

Difficult issues

There are some issues that still need careful consideration. (18)

The first is the fear that if abortion were banned, or just more restricted, we would return to the days of 'back-street abortions' and 'abortion tourism'. In the past this has been accompanied by wild claims of the risk to women's health from these procedures, many of which, such as the claim that 600,000 Brazilian women died from unregulated abortions each year, are now known to be untrue. While some women would undoubtedly travel to seek an abortion, a less permissive law would re-establish the value of human life within society. Such a change has recently occurred in Poland where following a change in the law abortions have fallen dramatically from 150,000 a year to 150 without any increase in maternal deaths. (19)

Secondly is the issue of abortion for fetal handicap. To start with, we should recognise that this makes up about 1% of the total in Britain, and in 2001 some 119 were performed on infants 24 weeks of age and over; an age when the child would have a good chance of survival if delivered and looked after in a neonatal unit. While no one denies the cost of raising a child with handicaps, in any other branch of medicine this would not be used as a reason for killing the patient. When asked, most people with disabilities also say that they are glad they were not aborted.

Aborting fetuses because they may be disabled sends an implicit message of rejection to people with disablities. More than that, the decision to abort arises from an implicit belief that these people will not lead a meaningful life. It also draws on a very real fear that because society is so reluctant to make space, financially and physically, for people with disabilities, the child will have very real problems once the parents are too old to provide care.

The third issue is the question of how to help women who become pregnant following rape or incest. Conceiving a child through someone else's act of evil is a terrible trauma, but following this by deliberately killing the fetus will compound the situation. A more positive response would be to provide all necessary support to the injured mother, including adoption services that can assist any who do not feel capable of supporting their baby.

Finally is the issue of performing an abortion to save the mother's life. When it occurs, however, the rationale is not that the fetus is seen to have less value than the mother, but that if no action is taken both will die. Aborting the fetus at least saves the mother's life.

Changing hearts and minds

Few people see abortion as a good thing, and for many women abortion brings with it a deep anxiety, grief and sense of loss. Some feel guilty of a deep betrayal of trust.

Christians believe that society needs to reconsider its attitude towards the fetus, as well as addressing the causes of 'unwanted pregnancies'.

We need to encourage people to make wise and responsible decisions about sex. We also need to redevelop the idea of pregnancy as a symbol of deep hospitality. As writer and broadcaster Elaine Storkey puts it in her meditation on Mary, pregnancy 'is the giving of one's body to the life of another. It is a sharing of all that we have... the growing fetus is made to know that here is love, here are warm lodgings, here is a place of safety'. (20)

As a hospitable community we should seek ways of providing support for lonely and frightened mothers, and for lonely and abandoned babies. In following Christ's example of compassionate love we need to offer women with unplanned pregnancies as much love and support as they require and to assist them in finding compassionate alternatives to abortion.

References

• Abortion Statistics. Series AB no. 28. London: Stationery Office. Table 1.
• Shain R. A cross-cultural history of abortions. Clinics in Ob and Gyn. 1986;13:1-17
• Genesis 1:27, 9:6
• Psalm 139:13-16
• Isaiah 49:1; Jeremiah 1:5; Luke 1:13-15
• Exodus 20:13
• eg. Exodus 22:2,3
• John 13:34,35; Romans 5:6; Galatians 6:2
• Ephesians 1:5
• CARE Centres Network. Freephone helpline 0800 028 2228. www.pregnancy.org.uk
• LIFE, LIFE House, 1a Newbold Terrace, Leamington Spa CV32 4EA. Tel 01926 421587. Website www.lifeuk.org
• The Rawlinson Report: The Physical and Psycho-Social effects of Abortion in Women (1994): HMSO
• David H. Post-abortion and post-partum psychiatric hospitalisation. Abortion: Medical Process and Social Implications. Ciba Foundation Symposium 1985;115:150-164. Pitman: London
• Beer D. Psychological trauma after abortion. Triple Helix. Autumn 2002 p5-6.
• Gardner G. Abortion and Breast Cancer - Is there a link? Triple Helix 2003 Winter p4,5
• Brind J, Chinchilli VM, Severs WB, Summy-Long J. Induced abortion as an independent risk factor for breast cancer: a comprehensive review and meta-analysis. J. Epidemiology and Community Health, 1997;50:465-467.
• Davidson T. Abortion and breast cancer: a hard decision made harder. Lancet Oncology, 2001; 2(Dec):756-758.
• Saunders P. Deadly Questions on Abortion - Part 2. Nucleus April 1998 p32-35.
• Murphy C. Abortion ship makes waves in Poland. BBC News. 1 July 2003. www.news.bbc.co.uk
• Storkey E. Mary's Story, Mary's song. London:Fount, 1993.