Is unwanted pregnancy a medical disorder?
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Abortion is often in the news. Yesterday, The Atlantic Wire reported a poll of Americans’ moral views, which found just under half of Americans believe abortion is morally wrong. Today, The Sun is running an article on the devastating effects on women of having abortions. And, a couple of weeks ago, the law in Ireland was changed to allow abortion under certain circumstances.
Whether (and under what circumstances) abortion is ethical, and whether (and under what circumstances) it should be permitted by law, are two of the most well known and fiercely debated issues of our age. I do not wish to engage with them here. Instead, I will argue as follows:
- Abortions cause suffering, and neither permitting them nor banning them is likely to reduce this suffering to an acceptable level.
- The best way of reducing the suffering caused by abortion is to reduce unwanted pregnancies.
- Current attempts to reduce unwanted pregnancies in the UK do not work well enough.
- Viewing unwanted pregnancy as more like a medical disorder and less like a social problem is likely to enable more effective measures to address it.
I then propose such a measure, and defend it against some possible objections.
First, then, permitting abortion and banning abortion both result in suffering:
Permitting abortion results in suffering. It is well-known that pro-life campaigners believe that abortion causes suffering to foetuses. There is no firm scientific agreement on when foetuses become capable of suffering. This is largely because investigating their capacity to feel pain is difficult given the very limited scope for observing behavioural responses. It would, however, be difficult to deny that late-stage foetuses are able to feel pain whilst also maintaining that newborn babies can feel pain. Further, it is difficult to read the details of at least some abortion methods without feeling horrified, as one pro-choice lawyer reveals in this review. Whilst foetuses are the main victims of abortion, however, they are not the only ones who suffer. Women who have had abortions also suffer as a result: dealing with an unwanted pregnancy is stressful and traumatic, and there is some research to suggest that women who have abortions are more likely to suffer mental health problems as a result, especially if they are young, have a history of depression, or already have children.1,2 (This research is controversial, however.3)
Banning abortion also results in suffering. Women who want to end unwanted pregnancies often turn to unsafe methods when they do not have access to legal, safe, medical or surgical abortions. An estimated 44 million abortions occur worldwide each year, almost half of which are unsafe (i.e. carried out by unskilled individuals, using hazardous equipment, or in unsanitary facilities).4 The suffering experienced by women as a result is perhaps obvious, but anyone who wants an illustration can find a chilling one here. And, of course, unsafe abortions are no more humane to foetuses than safe ones. Countries in which abortion is banned have far higher rates of unsafe abortion, 5 pointing to the conclusion that banning abortion is not an effective way of reducing the suffering that results from abortion.
Given that both permitting and banning abortion results in significant suffering, it is alarming how little is done to prevent women from needing to seek abortions in the first place. Existing efforts, it seems, are not enough. Whilst the UK runs sex education programmes and provides easy access to contraceptives free of charge, in 2011 nearly 190,000 abortions were carried out in the UK, the UK has the highest teenage birth and abortion rates in Western Europe, and those seeking abortions report not being aware of the contraceptive choices available to them, misunderstanding how to use them, or not using them at all. What can be done about this?
I suggest that we, as a society, should tackle this problem by viewing unwanted pregnancies much as we view certain disabilities and disorders, and by aggressively promoting contraception in the way that we promote routine vaccination. The effects of an unwanted pregnancy, after all, can be as devastating and disabling as the effects of some serious diseases and disabilities. In countries where abortion is legal, a woman with an unwanted pregnancy faces a choice between undergoing a medical or surgical procedure to end the pregnancy, or undergoing huge and difficult changes in her life for which she is emotionally, socially, and financially unprepared (these changes include continuing with the pregnancy and either raising the child herself or having it adopted). Where abortion is illegal, the choices she faces are even more grim. (And, of course, the outcome of an unwanted pregnancy for the foetus is unlikely to be happy either.) Unwanted pregnancies cause suffering on a scale comparable to that resulting from serious disease.
There are reasons why viewing unwanted pregnancy as akin to a disability or disorder may be unappealing. It does not, for example, reflect any biological malfunctioning: the body of a healthy woman suffering an unwanted pregnancy is working as it should. However, whilst this might be a good reason to avoid viewing unwanted pregnancy as a disease—definitions of which generally make reference to normal biological functioning—there exist many disorders and disabilities that do not involve the body malfunctioning in any identifiable, specific way. Many mental disorders take this form. Mental disorders differ from physical ones in that they generally lack clear tissue or molecular pathologies, and they can even arise despite optimal biological functioning. For example, gambling addictions arise when a useful and advantageous psychological function operates in certain environments. Similarly, many disability campaigners argue that some disabilities, like deafness, should not be defined in terms of biological malfunction, but as social constructs resulting from the fact that certain cultures (e.g. those in which people rely heavily on hearing sounds) place some people (e.g. those unable to hear) at a disadvantage. Such examples illustrate that there is a case for placing less emphasis on biological factors and more emphasis on social and environmental factors in our conception of disorders and disabilities: without attention to social and environmental factors there are some conditions (e.g. certain addictions) that we cannot even describe. Guy Kahane and Julian Savulescu have made such a case in defending their ‘welfarist’ account of disability, according to which a person has a disability if he has a physical trait that makes his life likely to go worse in the social, environmental, etc., circumstances he inhabits.6,7 According to a welfarist account, an unwanted pregnancy is a disability.
Currently, the prevalence of unwanted pregnancy in the UK is viewed as a social problem. There is a pervasive view that social problems are best addressed via education, public health/awareness campaigns, and other communication methods; and this is how the problem of unwanted pregnancy has been addressed in the UK. (Some social problems may also be addressed by legislation and financial incentives, but it is difficult to see how these could be made to work in this case.) These methods, as we have seen, are not working well enough. Taking seriously the idea that unwanted pregnancy is a disorder or a disability may encourage the employment of more effective methods of prevention. After all, as a society, in working to prevent disorders or disabilities, we do not generally take our methods to be restricted to types of communication (although these may play an important role). We consider medical methods too. Given the devastating effects of unwanted pregnancies, I suggest that medical methods of preventing them should be routine. Parents should be encouraged to have their (fertile) children use contraceptives the way they are currently encouraged to have their children vaccinated. By ‘encouraged’, I do not mean ‘given leaflets’, or subjected to similarly weak forms of persuasion. I mean that, when children reach an age at which there is judged to be a sufficiently high risk of their engaging in sexual activity, their parents should be asked to bring them to a clinic at which they will be prescribed contraceptives—ideally implants, injections, or other methods whose effectiveness does not depend on the patient continuing to use them correctly. Parents who do not respond should be chased up and sent stern letters emphasising the importance of contraception. This is analogous to the way in which parents are currently encouraged to have their children vaccinated. As with routine childhood vaccination programmes, participation should not be compulsory; but social pressure should be applied in order to ensure as high a level of uptake as possible.
There are likely to be objections to the idea that we should promote contraception the way we promote vaccination. I will try to anticipate some of them here.
Freedom. Would promoting contraception in the way I have suggested infringe on the freedom of young people to make their own contraceptive choices, and on the freedom of their parents to raise them as they see fit? Since I do not propose that using contraception should be made compulsory, I do not see my suggestion as unacceptably infringing freedom any more than promoting vaccination infringes freedom. Further, given that lack of knowledge about, and/or use of, contraception is responsible for unwanted pregnancies in young people, and that unwanted pregnancies significantly curtail freedom by limiting choices, the current failure to promote contraception effectively enough is more plausibly seen as infringing on freedom.
Encouraging promiscuity. One sometimes hears it suggested that encouraging young people to use contraception before they have considered having sex might encourage them to have sex. I am not aware of any evidence to support this concern, but let us overlook this point. There are two points to consider here.
First, people might worry about the spread of sexually transmitted diseases. I have advocated promoting certain types of hormonal contraception (implants or injections), since the effectiveness of these methods does not depend on the patient’s proper use of them. However, these methods do not protect against sexually transmitted diseases. So, some people might worry that, once they start using hormonal contraception, young people might be less likely to bother using barrier methods (such as condoms), which do offer protection against sexually transmitted diseases. Even if there were evidence to support this concern, I do not think it is compelling, however. I have advocated a system in which it is routine for young people to be summoned to a clinic to receive contraception. They can be informed about the importance of barrier methods while they are there. The very implementation of such a system is likely to foster the idea that—like vaccination—contraception is a necessity for everyone, not merely an option for unusually sensible or educated people. I would find it surprising if, on balance, the result of such a programme were to increase irresponsible sexual behaviour.
Second, some might worry that such a programme would encourage young people to have sex, and that this is a bad thing regardless of the consequences. This resembles the sort of worry expressed in the 1960s, when the contraceptive pill first became available, that women would become more promiscuous and that relationships between men and women would change. In part, this is exactly what did happen: we women began to have children later in life, we are able to enjoy sexual relationships that do not result in children, we are able to spend our twenties and thirties building a career and cultivating other aspects of life that do not involve raising a family. Whilst the prospect of these effects might have horrified some social commentators in the 1960s, society has changed since then and these things are viewed as mostly positive today. This lesson from history should caution us against placing too much weight on non-consequentialist worries about sexual promiscuity among young people today. Besides, sexual promiscuity in young people is arguably bad primarily because it increases the chances of those young people suffering unwanted pregnancies and sexually transmitted diseases. The programme I have advocated is intended to address the former problem, and is likely to help mitigate the latter. In any case, taking this worry seriously amounts to advocating maintaining the real threat of unwanted pregnancy as a deterrent against sexual promiscuity. As a deterrent strategy, this seems an unnecessarily draconian measure; rather like deterring people from entering one’s garden by planting landmines.
Sexism. I advocate giving young people hormonal contraceptives, by implant or injection. Whilst I favour giving it to all young people, these sorts of contraceptives are not available for men, so in practice my suggested programme would target only women. It would mean subjecting women but not men to medical treatment to prevent a problem caused by both men and women, and it might also encourage the view that contraception—and, perhaps, responsible sexual behaviour more generally—is the sole responsibility of women. Is this unacceptably sexist? I concede that it would be preferable if the programme targeted men and women equally, as it may do when male hormonal contraceptives become available. Even so, the measures I propose are designed to prevent unwanted pregnancy, which is a problem that—foetuses and unwanted children aside—inflicts its most devastating effects on women. I view it as unlikely that the negative effects for women of these measures would outweigh the current negative effects of dealing with hundreds of thousands of unwanted pregnancies in the UK alone.
1 Ferguson, D.M. et al. 2005: ‘Abortion in young women and subsequent mental health’, Journal of Child Psychology and Psychiatry 47/1: 16–24.
2 Major, B. et al. 2000: ‘Psychological responses of women after first-trimester abortion’, JAMA Psychiatry 57/8: 777–84.
3 Robinson, G.E. et al. 2009: ‘Is there an “abortion trauma syndrome”? Critiquing the evidence’, Harvard Review of Psychiatry 17/4: 268–90.
4 Sedgh, G. et al. 2012: ‘Induced abortion: incidence and trends worldwide from 1995 to 2008’ The Lancet 379/9816: 625–32.
5 Shah, I. et al. 2009: ‘Unsafe abortion: global and regional incidence, trends, consequences, and challenges’, Journal of Obstetrics and Gynaecology Canada 31/12: 1149–58.
6 Kahane, G. and Savulescu, J. 2009: ‘The welfarist account of disability’, in Brownlee, K. and Cureton, A. (eds.) 2009: Disability and Disadvantage (Oxford: Oxford University Press): 14–53.
7 Savulescu, J. and Kahane, G. 2011: ‘Disability: a welfarist approach’, Clinical Ethics 6/1: 45–51.