Abortion and fertility treatment: Whose right to choose?

Commentary by Ann Furedi, chief executive of BPAS.

The philosopher John Stuart Mill said that it is better for an individual to encompass his own destruction than ‘the evil of allowing others to constrain him for what they decide to be his good.’ This essentially sums up my view about the decisions that people face regarding their reproductive future.

In debates about abortion I am often challenged by people who ask: ‘Don’t women sometimes make the ‘wrong’ decisions?’ ‘How do we stop people from making a ‘bad’ choice?’ ‘How do we know they’re not going to regret their abortion?’ ‘Do you, personally, always agree with what women decide?’ ‘What about the woman who comes to you wanting an abortion because, say it interferes with her holiday, but who says she wants to get pregnant again the following year?’ ‘Can you say that she’s making the right decision?’

I always feel that it’s not for me to say whether the decision any woman makes is right for her. Some women make decisions around abortion that I, personally, think are wrong. I’ve had some interesting discussions with our counsellors, where I’ve been told: ‘You can’t ever say that women make the wrong decision because the decision making process is so complicated. Maybe she is saying that she wants the abortion so she can go on a skiing holiday, but, behind this, there will be a lot of other reasons’. That may be true, and I believe it usually is. But, what if a woman is making her decision ‘just’ because she wants to ski that black run? Or because she wants her dress to fit for the dance?

I believe that, for whatever reason a woman makes a decision about the future of her pregnancy, it is for her to make because, ultimately, she is the person who will live with it. When that woman looks at herself in the mirror every morning, she knows she lives in the life shaped by what she decided: either she has a child as a result of that choice, or she doesn’t.

It is because I have a firm belief that people should, and must, take responsibility for their decisions that I think that we need to be respectful of these choices, even when we do not agree with them. I believe it is wrong for us to deny people the capacity to make these intimate, personal choices. Tolerance of this freedom for others to decide what we would not is the price that we pay for living in a liberal society.

In relation to fertility treatment, as with abortion, I can appreciate the frustration that clinicians feel when women seem to be making irrational and unwise choices. I understand why, sometimes, they feel that couples should be prevented from making choices that may not lead to the best outcome - for example, when a couple insists on using two or three embryos when a single-embryo transfer would be far preferable from a clinical point of view. But, at the end of the day, personally, I am very hostile to legislation and regulation that prevents (although some would say ‘protects’ ) people from being able to make the wrong choices. For me, the freedom to make personal decisions in these matters is an issue of principle which is related to the question: ‘Whom do we trust?’, and our view on whether people can be responsible for making complex decisions for themselves.

I assume that people are generally capable of making rational, sensible decisions. When it comes to single-embryo transfer, for example, the onus should be on clinicians to communicate effectively and so convince patients of the advantage of this. And not seek to hide between rules and regulations that allow them to avoid this engagement, by simply maintaining a course of action is ‘not allowed’. Of course, this is what many doctors do – they have an ‘adult’, respectful dialogue.

If I were a 39-year-old woman undergoing fertility treatment, I would want to ask my doctor: ‘in my own specific circumstances, what is the best way of giving me my best chance of having a successful healthy pregnancy?’ If I believed that my doctors and I shared the desire for the best possible outcome, why would I not take their advice? That advice might be to use three embryos, or one embryo, or whatever, but I would want it to be a rational decision, determined by a clinician’s assessment of my personal needs. I certainly would not want any decision that requires clinical assessment to be determined by the views of the members of a regulatory authority made up of actors, bishops and journalists. Nor would I wish it to be made by parliamentarians – whether elected or not.

Clinical decisions should be taken according to what will give the patient the best outcome. Of course, these choices are made within a moral framework but women and their doctors have the capacity to make these decisions for themselves, and the capacity to manage the consequences.

I am not insensitive to the debates concerning the welfare of the potential child. Nor about the implications of individual choices for the rest of society. But a woman who is taking the decision to end a pregnancy is taking a decision not to have that child at all, to end the life before it has started, and there is no child whose welfare we need to consider. This is true regardless of the reason why the pregnancy is terminated.

Many of us may have very strong views about the morality of bringing a child into the world, or of deliberately ending that life before it’s begun. Or we may have very definite views about bringing a particular type of child into the world – for example a child that has a learning disability, or a severe physical and, perhaps, very painful impairment. Our views may differ, according to the qualities that we value, which is why I believe strongly that such choices regarding life and death, must remain with those most intimately affected by that decision. Putative parents, in consultation with their doctors, must make their own decisions as to whether or not they are prepared to face the relative risks of a multiple pregnancy – or the consequences of a congenital abnormality or those of terminating the pregnancy.

When it comes to these matters of family life and procreation, it really should be down to the parents, and ultimately the woman who will be carrying the pregnancy, to make that decision. Even if that decision is one that we disagree with or that goes against the grain of what society holds to be good sense. The abilities to exercise autonomy in decision making, and to base our choices on complex moral considerations, are central to what makes us human.

We need to be free to make the wrong choices if we are to be free to make the right ones. When governments, or their regulatory committees, take away our capacity to be wrong, they simultaneously take away our capacity to be right. And that is a degrading and intolerable assault.

This is an edited version of a speech given by Ann Furedi at the Battle of Ideas, 31 October 2009. Ann Furedi was speaking in a personal capacity.

Also read:

A Doctor’s Right to Choose: The dishonesty of English abortion law, by Professor Sally Sheldon. Abortion Review, 6 November 2009

Three’s a crowd? The battle over population and reproduction, by Dr Ellie Lee. Abortion Review, 6 November 2009