On medical termination of pregnancy

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Mgr Dr Joe Vella Gauci

Link to the Maltese version of this article ...

The matter at hand in reality is quite simple. However, it has caused such a national stir and polarisation that it has become inordinately complex. It has become a maelstrom of religious, moral, clinical, legal, trade-unionist, and even petty concerns. In my opinion, there are four steps that need to be tackled in order to untangle what has become a Gordian knot:

  1. the trigger to the discussion;
  2. the issue of foetal viability;
  3. decision by committee;
  4. a matter of conscience.

1. Firstly, this matter arose consequent to unfortunate premature rupture of membranes (PROM) in a woman who happened to be holidaying in Malta. Although, the case is currently subject to a court-case, lengthy court proceedings are superfluous to the understanding of the typically straightforward clinical scenario that unfolded. At fifteen weeks, the prospective mother requested termination, but the local specialists refused to abort a beating-heart foetus. The specialists instituted best medical care coupled with the time-honoured medical strategy of watchful waiting. At no point during her admission, was the prospective mother in danger of loss of life, as evidenced throughout by her normal clinical and blood parameters. As current legislation stands, the local specialists were fully justified to refuse termination because, with the treatment provided, the medical literature cites a 20-80% chance of survival for the beating-heart foetus. The prospective mother was airlifted to a country where abortion is legal, wherein and for all intents and purposes, the beating-heart foetus was terminated. This sequence of events has but one logical conclusion – this “index” case should have never been used as the basis or trigger for a change in legislation.

2. Secondly, there is the issue of viability. This refers to the fact that once delivered by vaginal or operative means beyond the 24th week of pregnancy, a foetus is considered to be able to survive with or without medical support. Much is being said about the fact the new amendment will stipulate that a viable foetus should be delivered in case of maternal distress. But this issue should not even be allowed to feature in any serious discussion about the matter. Preserving a viable foetus is universal medical practice. Hence, when a prospective mother develops life-threatening conditions beyond the 24th week, our specialists procure delivery of the viable foetus in order to allow the survival of both mother and foetus. It is simply preposterous to claim that we are legislating in favour of such a strategy because even the most liberal abortionist law (such as that in the United Kingdom, to mention one example) stipulates this as sine que non. In the United Kingdom, abortion of viable foetus up to term (40 weeks) is only allowed in cases of deformity such as Down’s syndrome. In fact, mere months ago, an English court of appeal quashed the attempts of a Down’s syndrome person to abolish the practice.

3. The question is, really and truly, about the foetus which is not yet in its 24th week of gestation. A balanced legislation in favour of the mother, healthcare practitioner and the non-viable foetus (pregnancy less than 24 weeks) is deceptively easy to construct. In my opinion, the denominator in this formula should be life and in these 2 paragraphs I shall only consider non-viable pregnancy. The healthcare professional taking care of pregnancy, is in the unique clinical position of being responsible for two patients concurrently. The worker knows that complications leading to the death of the prospective mother will necessarily lead to the death of the foetus, as ante-mortem as well as post-mortem delivery will result in a non-viable foetus i.e., a foetus that is unable to survive with or without medical assistance. Therefore, the healthcare worker can only aspire for the best outcome in any given clinical distress scenario by preserving the mother’s life. When a prospective mother has a proven life-threatening condition that necessitates termination, the best outcome can only be achieved by termination. Consider the case of an 18-week pregnant woman diagnosed with aggressive acute leukaemia (blood cancer). Delaying equally aggressive chemotherapy by more than a week will be life-threatening for the women. This treatment will almost certainly lead to the non-viable foetus’ intra-uterine death or at least very serious deformity. The best outcome in this scenario is a termination to allow the mother timely treatment. Likewise, the best outcome in life-threatening internal haemorrhage from tubal ectopic pregnancy is termination by surgical removal of the non-viable pregnancy. By contrast, the best outcome in an 18-week pregnant woman with life-threatening ruptured appendicitis or cholecystitis or diverticulitis would be an emergency organ-resection operation and not a termination of the pregnancy.

In my opinion, medical termination in non-viable pregnancies shall only be allowed at Mater Dei Hospital, in situations where, in order to preserve a pregnant woman’s life, the treatment of a life-threatening condition or a life-threatening complication necessitates such termination. I suggest that considering this legislation, the final decision on termination shall be taken by a committee of three experts – the duty gynaecologist, a Medical Council nominee with expertise in medico-legal aspects and the duty family court magistrate. All three shall be unanimous in their decision in order for termination to proceed lawfully.

4. Finally, I have to remark that it is mendacious and patronising to consider a pro-life stance as backwards, out-of-fashion and not modern. To make matters worse, this matter was never discussed pre-election, it does not feature in any electoral manifesto, and it was never submitted to a public consultative process. Inadvertently, it has become a very personal issue for legislator and the individual at large, alike. It is fallacious to state that one or the other can reach a clean and self-disciplined conclusion without recourse to one’s conscience. Whether a person is pro-life or pro-choice, we are all unremittingly in favour of the preservation of a woman’s life that is jeopardised by life-threatening disease or life-threatening complication. These two camps diverge on the matter of health and well-being. There is wide consensus amongst experts in the modern fields of gynaecology, surgery medicine and psychiatry that most conditions that affect the pregnant woman’s health and well-being can be managed with treatment that obviates the resort to abortion. There is no doubt that such open terms will inevitably pave the way for indiscriminate abortions because such terminology is in fact the same used in abortionist legislation abroad. There can be no sound reason for claiming that such terminology will not result in indiscriminate abortion in our country.

Perhaps many readers will have by now either dismissed or skimmed through my opinion by utterly ignoring me as a priest without medical expertise, and presumably, a callous of the male species bereft of empathy and devoid of the right to speech on a subject matter appertaining exclusively to women. However, intrigued as I am with the topic, my conscience forbade me from laying idle. This opinion piece emanates from lengthy discussions I held with several doctors and practitioners – including some who certainly do not classify themselves as conservative on the conservative-liberal spectrum. Entitled to my view on the topic, it is my most sincere wish not to see Malta being ushered into the international abortionist community, something I have serious moral and ethical qualms about. I would, if I may, advise in the public forum we learn from others’ mistakes and realise that it is not entirely wrong that in matters of conscience, we cease to join the chorus and forge our own path. We only have so long to make our mark. In the end, when it’s over, all that matters is what we have done.


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