The Heart and the Abyss: Preventing Abortion

The object of this study is a reconsideration of the abortion praxis in the United Kingdom (U.K.) and the Netherlands. To achieve this aim, a moral philosophical framework elaborated by Paul Ricoeur in his essay “The problem of the foundation of moral philosophy” has been applied. This approach makes it possible to integrate empirical data, ethical and theological presuppositions and to make more concrete recommendations for the current abortion praxis and for future research.
Ricoeur starts his inquiry with the notion of freedom as the principle source underlying ethics which is aimed at the ‘good life’. He states that one only arrives at a concept of ethics if one acknowledges the freedom of the other, of the second person, as similar to one’s own freedom. Next, as a third step one has to take into account the mediation of institutions. When referring to ‘institutions’, Ricoeur distinguishes values, norms, imperatives, laws and natural laws. As regards values, one might think for instance of the value of life itself, or of physical and mental health. Regarding norms, the relevant issue in the abortion dilemma concerns the status of the human embryo. When discussing imperatives, Ricoeur considers both commandments a person imposes on himself due to the working of his conscience, and the commandments imposed by an authority such as the State, the parents or the family. Imperatives imposed by the State are laid down in the law. In this research, the abortion legislation the U.K. and the Netherlands is analysed and assessed in two case studies, in order to determine the extent of consistency, as well as the consequences for those who are involved.
The concept of law adds the possibility of universality to the notions of values, norms and imperatives. Laws have the scope of universality in order to protect certain values. Similarly to Kant in his theory of maxims, Ricoeur introduces two simple questions which could function as a criterion for universality in decision making processes: “Would I want everyone else to do the same?” and “Could my desire serve as a universal law?”
Finally, Ricoeur seeks to integrate the evangelical perspective within the ethical order, which is elaborated in the final chapters of this study with regard to the abortion dilemma. After the call of the Second Vatican Council for an openness to the world, the integration of results of social scientific research has led to a focus within theological research on human experience and practice. Moral theology as a science shows that the search for the protection of universal values such as life or love call upon existential questions which often are not answered in a satisfactory way in social ethics.
In chapter 1, the juridical framework for the legalization of abortion in the U.K. and the Netherlands is discussed. Both in the U.K. and in the Netherlands abortion has been legalised under certain conditions until the 24th week of pregnancy. The British Abortion Act, which has been accepted by the U.K. Parliament in 1967, has a number of grounds on which an abortion could legally take place. The vast majority of abortions (97 %) takes place under ground C, which literally means that the doctor expects that the continuance of the pregnancy would involve a greater risk of injury to the physical or mental health of the pregnant woman than if the pregnancy were terminated. In less than half a percent of all British abortions there is a risk of physical injury, so in almost all cases the two medical practitioners involved declare that they presuppose a mental risk if the pregnancy were to continue. In the U.K., in 1990 the upper gestational limit for legally performing an abortion has been brought back from 28 weeks to 24 weeks. Other amendments failed.
In 1981, the Termination of Pregnancy Act was accepted by the Dutch Parliament after lengthy debates. In 2005, the functioning of the Act was evaluated by Mechteld Visser et al., but this did not lead to fundamental amendments. A difference between the laws in both countries is that in the U.K. it is permissible for girls under 16 years to have an abortion carried out without parental consent. The mandatory cooling-off period of five days in the Netherlands does not apply in the U.K. Neither does the U.K. have a legal obligation to discuss alternatives for abortion during the first consultation. Since 2007 the 20 weeks ultrasound scan is offered to all Dutch pregnant women. In the U.K. this has been common practice for a longer period.
In this chapter the consequences of the legal abortion praxis in the U.K. and the Netherlands are presented by means of statistical data. Since the 1970s the number of abortions in the U.K. has more than doubled. In the Netherlands, the number of abortions since 1990 shows an almost constant increase, only in the last few years a stabilisation has occurred. Statistics show that in the U.K. significantly more abortions are performed than in the Netherlands, in particular the number of teenage pregnancies followed by an abortion is significantly higher.
In both countries, the number of abortions among ethnic groups is higher than among the native population. In addition, there is evidence that young immigrant women are at risk of sexual abuse, which occurs more frequently than with native women. In addition, there has been an increase in the number of cases of sexually transmitted diseases, which entails risks to the health of the embryo.
Mark Levels’ social scientific study shows a link between restrictive abortion laws in several European countries and a reduction in the number of abortions. Similar research from the U.S. also shows that stricter abortion laws or a higher price of abortion could lower the number of teenage pregnancies and of procured abortions.
During the last few decades thoughts on abortion have been characterised by medicalization. In the U.K. this phenomenon is visible because almost all abortions are performed presuming that the continuance of the pregnancy would involve risk of injury to the mental health of the pregnant woman. One major problem of the political debate as it has taken place in the U.K. is that ethical and moral aspects of abortion were explicitly excluded from the Parliamentary discussion. The British Parliament did not commission research into the effectiveness of the current abortion practice, as has been the case in the Netherlands. Therefore, the results of the Dutch evaluation of the functioning of the Termination of Pregnancy Act offer various insights which could also be valuable for the British situation.
Four inconsistencies have been found between the requirements of the Dutch Termination of Pregnancy Act and the current Dutch abortion practice:
1) Criteria are lacking to determine what constitutes an emergency situation, whereas the law states that there must be an emergency in order to choose for an abortion.
2) The legal requirement that alternatives to abortion ought to be discussed during the first consultation is often neglected.
3) Research shows that the medical staff of abortion clinics and G.P.’s do not always offer sufficient and understandable information with regard to the physical and mental risks and effects of abortion. An exchange of ethical views is even rarer.
4) The medical staff tends to focus on legal requirements and on the woman’s decision, rather than on the content of their own decision. The Dutch Termination of Pregnancy Act however requires that both the woman and the doctor are taking an autonomous decision.
In the analysis of the abortion legislation and practice in the U.K. and the Netherlands, it is concluded that although the current legislation in both countries tries to protect women’s autonomy, unborn human life is not adequately protected with respect to the original intention of the legislator. Within the current counselling practice, little attention is given to alternatives for abortion. The male begetter has no legal status whatsoever in the decision making process regarding unintended pregnancy.
In chapter 2, a historical background of the legalization of abortion in the U.K. and Netherlands has been sketched. In the second half of the 19th century, the first feminist wave began to develop in both countries. Influential women such as Marie Stopes and Aletta Jacobs focused in particular on women's emancipation and on education in relation to means of birth control, but they did not favour abortion. Representatives of the second feminist wave in the 1960s and 1970s saw the legalization of abortion as a means to promote emancipation and to counter the problem of illegal abortions. In those years, public opinion shifted in the same direction, both in the U.K. and in the Netherlands. During the third feminist wave, several authors pointed out the limitations of the ideal of autonomy and also brought to light the desire for inclusiveness of men in making reproductive choices.
In this chapter the concept of autonomy is discussed in relation to the liberal abortion legislation as it is enforced in countries such as the U.K. and the Netherlands. It addresses the question of how ethical theories developed by Immanuel Kant, Martha Nussbaum and Judith Jarvis Thompson are doing justice to finding the balance between autonomous choice and respect for the unborn life.
In the recent literature, self-determination is seen as the defining characteristic of autonomy. According to Kant an autonomous man “gives” a universal law to himself. Another premise of Kant is that man must always be considered as an end and never as a means. Applied to the issue of abortion, a Kantian philosophy could be helpful if the focus is on an increase of human capabilities. In contrast, an autonomy approach based on available opportunities could result in a disadvantageous negotiating position for women compared to men. Counsellors who give insufficient attention to the possibilities a woman has to bring her pregnancy to term may also impede her autonomy. Moreover, from a philosophical point of view, it is impossible to decide for another human being whether to live or not to live is the best option.
In their approach, Rosalind Dixon and Martha Nussbaum start from the growth of human capabilities, but in the application of this approach they disregard the fundamental difference between abortion and therapeutic interventions: therapy is directed at continuity, whereas abortion involves the immediate death of the foetus.
Paul Ricoeur points out the difficulty of attributing a particular series of events to a particular agent, because the actions of each one of us are so strongly intertwined. Applying Ricoeur’s phenomenology to the abortion issue, it becomes clear that the autonomy of the agent, in this case a pregnant woman, could be threatened when the male begetter reacts negatively or with indifference to her pregnancy. On the other hand, it could be lifesaving if future arrangements could be discussed, possibly with the help of a counsellor or with other persons in their families or peer group.
According to Ricoeur, values, norms, imperatives, laws and natural laws could generally play a mediating role within the trajectory of the realization of freedom in intersubjectivity. In chapter 3, the focus of attention will be on the values of life and health of the woman, in particular after having made a choice for a procured abortion. This chapter provides an investigation of scientific evidence regarding psychological, psychiatric and physical risks and effects of abortion on women, based on international literature published between 1985 and 2015, as well as some recommendations for further research.
Although a majority of Dutch women who were questioned by Mechteld Visser et al. indicate that the satisfaction with care after an abortion is high, these results do not imply that these women were satisfied with the fact that they had the abortion as such. Some of these women are struggling with psychological and psychiatric problems, sometimes many years later. Evidence shows that some 42,000 British women and 6,000 Dutch women each year suffer from severe mental health problems after abortion.
Research on the mental health effects of abortion often encounters several methodological difficulties. In particular, the lack of a proper control group in several studies needs to be mentioned, because of which possible effects due to other confounding factors cannot be ruled out. The conclusion is drawn, based on a longitudinal study by David Fergusson et al. conducted in New Zealand, that experiencing a procured abortion implies an increased risk of mental health problems for women of about 30%. Future interdisciplinary research on mental health effects of abortion should include the ethical and moral considerations of the decision-making process. Research should be conducted by means of retrospective and prospective data, using qualitative and quantitative research strategies.
As regards the physical risks and effects of procured abortion, various international studies point to the risk of preterm births in pregnancies following an abortion. Preterm births are associated with a higher prevalence of major birth defects. Other research points out that there is an increased risk of complications after procured abortion in the case of an existing chlamydial infection. In recent years a number of Asian studies from developing countries have reported a relative risk for women with a history of induced abortion to develop breast cancer. However, several Western studies did not find an independent link between abortion and breast cancer. This difference might be explained by the stronger role of confounding factors, such as delayed child birth, nulliparity and the use of oral contraceptives among Western women. Methodological problems such as the lack of a sufficient time span in the study design may also impede this kind of epidemiological research. In other studies it has been shown that giving birth and breastfeeding reduce the risk of breast cancer. Finally, several studies conclude that there is a link between procured abortion and the risks of suicide, psychiatric admission or self-harm.
A review of the 2005 Dutch evaluation of the abortion legislation offers an insight into the reasons for abortion. Women mention a variety of relationship conflicts and problems, more often than financial reasons. Qualitative psychological research shows the same pattern. The evaluation indicates that about a quarter of Dutch women has doubts about abortion, both before and after the intervention. Similar international research shows higher percentages. It has also been found that ambivalent feelings are common during (unintended) pregnancies. Being attentive to such feelings could be very relevant for the decision making process after the discovery of an unintended pregnancy and for the involvement of the male begetter in this process. More attention should be given to situations where domestic violence has occurred, before a decision is made.
In chapter 4, the focus of attention are the rights and value of the human embryo. In this chapter and the next, following Ricoeur’s steps in his search for a foundation of moral philosophy, a transition is made from values to relevant norms regarding procured abortion. First, a description is given of normal embryonic development. A crucial argument in the abortion debate is that conception is a unique event when new human life is created. Embryonic development is characterised by an intrinsic finality, guided by the DNA in the cell core, which is present and active in its specific combination from the moment of conception. Embryonic development proceeds gradually, continuously and coordinated.
Therefore, the question is raised of the extent of legal protection of the human embryo. A comparison with international law shows that the view that human life is worthy of protection from conception onwards, has not been included in United Nations and European Union conventions, nor in Supreme Court verdicts in various European countries. Among jurists, an international consensus has not yet been reached regarding the question when human life and the related right to life begins. From a bioethical point of view, however, the inherent dignity of the human embryo should be distinguished from attributed dignity and recognised as such.
A comparative analysis of European international law shows that despite some recognition of the need to protect the dignity of the human embryo, this has not resulted in a recognition of the right to life in the sense of Article 2 of the European Convention of Human Rights.
The central and normative question in the abortion debate concerns the status of the embryo as a human being and as a person. Both in the U.K. and in the Netherlands, scientific experiments on embryos are allowed up to 14 days after fertilisation. In the U.K. this was adopted on the basis of recommendations of the Warnock Committee. Mary Warnock argued that the embryo could not be considered a human being before the formation of the primitive streak after about 14 days, because of the possibility of monozygotic twinning. However, so far it has not been observed exactly how monozygotic twinning takes place. In animals, differences in developmental characteristics are already demonstrated in blastomeres of 2 or 4 cells; twinning could therefore be ‘programmed’. According to Warnock and others, the embryo develops gradually. This raises the metaphysical question of whether the ensoulment of the embryo occurs immediately after fertilisation or after a delay. According to Rose Koch-Hershenov, monozygotic twinning should be considered as the splitting of two human beings who shared one body (cf. Siamese twins). This hylomorphic metaphysics provides an explanation for the steady growth of the embryo from fertilisation onwards. The possibility of monozygotic twins is therefore as such not a tenable argument against the thesis of immediate ensoulment.
Jeff McMahan, Ronald Dworkin, Hugo Tristram Engelhardt and others argue that being a person starts with rational capacity, or even later. Such a view leads to a dualism between a human being and a person. After all, there is no identifiable moment of substantial change in the development of the human embryo.
As a biological argument for the proposition that a human embryo needs to be considered as a person from conception, it is put forward that a zygote is the beginning of a human being with active potentiality. As a philosophical argument for this proposition Robert Spaemann states that being a potential person is impossible.
In chapter 5, philosophical backgrounds are considered with regard to the reproductive decision making process. Paul Ricoeur’s phenomenology could offer insights with regard to the relation to the foetus and one’s ethical intention. According to Ricoeur, the second component of the ethical aim of a good life is focused on solicitude with and for others. The phenomenological hermeneutics of the self shows a dialectic of the Same and the Other which attests that the Other is not only the counterpart of the Same but at the same time decisive for its own self-designation. If the ethical aim of self-esteem becomes enclosed in itself, then the reflexion on openness towards the other could be in great danger. Applying Ricoeur’s phenomenology to the abortion dilemma, attention is drawn to the possibility of friendship with the unborn child. Ricoeur also points out that the ethical intention has to be realised by mediation of just institutions. Here, he refers to Hannah Arendt, who concludes that the right of every individual to have rights is even more fundamental than the pursuit of justice and freedom.
It is further argued that the rational choice theory on fertility is unsuitable for the foundation of a choice for abortion, because economic, social and moral costs are not to be compared. This kind of decision making should be considered as an improper application of the principle of proportionality, also called consequentialism, because the future qualities of the foetus remain unknown and therefore cannot be compared to any possible benefits of abortion.
Based on the argument that procured abortion deprives a foetus of his or her future like ours, a future which is potentially valuable, Don Marquis argues that in almost all cases procured abortion is an immoral act. From a theological point of view, the potentiality to grow into an adult is already present in the embryo from conception. However, in philosophical discussions such a metaphysical notion of potentiality is criticised. In this regard, the concept of human dignity within bioethics and international law is taken into consideration. Daniel Sulmasy distinguishes three dimensions: attributed, intrinsic and inflorescent dignity, the latter dimension being an expression of the intrinsic value of human beings and referring to the process which could lead to human excellence. It is obvious that persons with a certain anomaly share in human dignity. Similarly, every human embryo possesses an intrinsic human dignity, even if this still has to flourish.
John Rawls can be considered as a representative of postmodern liberal philosophy. His concept of justice only includes human beings after their birth. Rawls is implicitly using a metaphysical concept of the human person, which denies the continuity of human existence and human development before and after birth.
The equality of every individual implies that in reproductive decision making, one should focus on every human being as a whole and not just on a particular anomaly or disability, as often seems to happen at the discovery of a certain anomaly after prenatal diagnosis.
An ethical conclusion about procured abortion is formulated, using the principle of acts with double effect. According to this principle, which is derived from natural law theory, an act could be morally justified when four conditions are met simultaneously: 1) The act must not be wrong in itself; 2) The agent’s intention must be right; 3) The good effect must not be realised by negative side-effects and 4) There must be a proportionately grave reason for doing such an act with negative side-effects.
It is concluded that morally speaking, only in very specific medical cases an abortion could be performed, accepting the foetus’ death in order to save the mother’s life. In these exceptional circumstances all four conditions of the principle of acts with double effect are met. In all other cases, ways must be sought to avoid abortion, which is not only a woman’s responsibility, but also a responsibility of her partner, of other persons directly involved and of society as a whole, because alternatives should be provided.
Parental and societal responsibility is equally applicable in the case of a healthy child as in the case of a child who is expected to have a certain anomaly or disability. The tendency to medicalise pregnancy is shown by the way in which parents and medical professionals deal with the results of prenatal diagnosis, especially if the foetus is found to have a certain anomaly. In this regard, medicalization means that the decision to continue or terminate the pregnancy is often reduced to the question of how future suffering might be prevented.
According to Paul Ricoeur, the idea of law should add to our notions of value, norm and imperative a requirement for universality, a potential universalisation. In chapter 6 an analysis is made of the historical search for a universalisation of the ethics of abortion. It is argued that basic values such as autonomy, creativity, love and friendship and finally discovering and living the truth could be threatened as a result of an abuse of freedom. According to Ricoeur, the problem of the recognition of the freedom of the other is the central phenomenon of ethics. Returning to the two Kantian questions which were posed as a criterion for universality in decision making processes: “Would I want everyone else to do the same?” and “Could my desire serve as a universal law?”, both questions have to be answered in the negative as regards the option of procured abortion and its current legalisation, because of the threat of these four basic values and the violation of the dignity of the foetus.
In this chapter a historical analysis is made of the moral theological views regarding abortion throughout the centuries, in particular within the tradition of the Catholic Church. In the Bible there is one passage, Exodus 21: 22-25, which explicitly refers to abortion, in this case a miscarriage as a result of a human conflict. This passage should be seen in the context of the Ten Commandments and in particular the fifth commandment “Thou shalt not kill” (Ex. 20, 13; Deut. 5, 17). Jesus of Nazareth accentuates this commandment with the intention of bringing fulfilment to the ancient writings in the Law and the Prophets (cf. Mt. 5, 17-22).
Christians took over respect for human life in all its stages of development from the Jewish tradition. This attitude brought them into conflict with the surrounding Roman culture. From the Didachê onwards many authors in early Christianity and the Middle Ages condemned the act of procured abortion, regardless of discussions on fully formed and unformed foetuses. Such discussions were hindered by the fact that the egg-cell and human genetics were still unknown.
Reflection on the relation between body and soul by Thomas Aquinas and others has led to the confirmation of the Catholic doctrine of the unity of body and soul. A few decades later the dogma of the immortality of the soul was confirmed. During the Renaissance and the Enlightenment, the Church’s teaching on abortion has been integrated in canon law. The teaching of how to deal with exceptional situations of indirect abortion was also further elaborated. In the 19th century, after the discovery of the egg-cell by Karl Ernst von Baer in 1827, an international consensus grew among theologians regarding the immediate ensoulment of the fertilised embryo.
In the 20th century, the Church’s doctrine giving equal value to the life of the mother and the unborn human life was confirmed. The Catholic point of view starts from the inviolability of life from the moment of conception, after which the embryo is to be respected and treated as a person. The Church is opposed to governmental support for direct abortion. The care given to young mothers and children by religious women and men, which initially had been strongly expanded, gradually disappeared in the course of the 20th century in Western Europe. The publication of the encyclical Humanae Vitae in 1968, several years after the Second Vatican Council, resulted in a controversy about autonomy in relation to contraception. From the 1980s, opposition to abortion extended to include criticism of scientific experiments with embryos. The Church is not principally opposed to prenatal diagnosis, but only if this is considered as a forerunner for abortion. Decisions which go against life itself cannot be reasonably demanded from another human being. As a theological reason for this point of view it is argued by Mariéle Wulf that a free, moral decision should take into account the greater possibility, the greater life.
With the theology of the body, John Paul II made a contribution to pastoral and moral guidance for responsible parenthood. In their pastoral activities, members of the Church should always make a distinction between a wrongful act and the person who performed the act and who does not lose her or his dignity. As is also shown in canon law, it depends on the circumstances whether or not one could speak of guilt in the case of abortion.
As regards the Christian interpretation of conscience and the formation of conscience, the Church affirms the authentic human freedom and autonomy in earthly affairs, as long as this autonomy does not violate the respect for the human person or is opposed to life itself. The distinction which has been made in moral theology between synderesis (the indelible and infallible conscience) and conscience (the fallible conscience) is still helpful for an understanding of the relation between human conscience and human autonomy.
In chapters 7 and 8 the focus is on how procured abortion can be prevented. The main available alternatives for abortion in the U.K. and the Netherlands are dealt with, such as professional, voluntary or financial assistance to young parents bringing up a child after an unintended pregnancy, as well as adoption and foster care. The organizational structure in which these alternatives are embedded, is also examined. It is concluded that the existing organizational structure in the U.K. and the Netherlands to provide alternatives to abortion is insufficient for stimulating greater prevention of abortion.
Following this discussion, the relationship between education, abortion and contraception is considered. Within the health care sector and other forms of assistance it is widely argued that contraception is a means to prevent abortion. In contrast, the Magisterium holds the view that sexuality as an authentic act of love also includes an openness to new life. Knowledge in the area of Sex and Relationship Education (SRE) as it is taught in Dutch schools is strongly influenced by the potential risks of unsafe sexual behaviour. Research on SRE in the U.K. recommends that in education more emphasis is laid on building and maintaining relationships. Evaluation of the SRE-programs in schools in the U.K. and the Netherlands stresses the need of parental involvement in the provision of SRE, as well as the right of parents to withdraw their child from elements of SRE-programs.
Recommendations are made regarding partner involvement in the decision-making process regarding unintended pregnancy, as well as with respect to informational, emotional and spiritual aspects of guidance during the decision making process. Virtue ethics could offer a theological as well as a secular contribution to a more prudent attitude of men and women regarding the quality of their relationship and also to a more careful decision making process after the discovery of an unintended pregnancy.
Next, the question is raised of how to deal with results from prenatal diagnosis, especially if it is found that the foetus probably has a certain anomaly. With the increasing possibilities of prenatal diagnosis, it seems that in our society an increasing pressure is laid on future parents to choose for an abortion when they are expecting a disabled child. The principle of integrating all dimensions of care, including the spiritual dimension, needs to be applied in the case of counselling parents who are expecting a child with a certain anomaly.
A recent development regarding the role of the man and his responsibility as begetter of the embryo has been the use of DNA testing as a legal means to prove fatherhood. This could lead to a verdict obliging the father to either actively or passively (financially) contribute to the child’s upbringing.
Finally, pastoral aftercare (after an abortion has taken place), should focus on self-acceptance, due repentance and openness to God’s forgiveness and peace.
It is concluded that professional assistance in relation to pregnancy dilemmas is too one-sidedly woman-focused. More attention to underlying relationship problems and to alternatives for abortion would be desirable in order to protect the unborn child and also to prevent short term and long term physical, psychological and spiritual problems for women. As part of counselling or pastoral care, alternatives to abortion should be discussed, also if after prenatal diagnosis a certain anomaly of the child is diagnosed or suspected. For all these reasons, the political and ethical debate on the prevention of abortion in the U.K. and the Netherlands needs to be reopened.