Ethical Issues Arising From The Involvement Of Psychiatrists In Late Termination Of Pregnancy

Dr Kirsty Morris

Background Psychiatrists have a long history of

involvement in advising decision making in termination of pregnancy (TOP)

Prior to liberalization of abortion laws, TOPs were often permitted if the mother’s life was at risk from psychiatric or medical conditions

Once abortion laws were liberalized, the involvement of psychiatrists declined

Legal setting Abortion legislation in all Australian

states was originally based on British law

In 1967 the United Kingdom Abortion Act was passed

Most Australian states then liberalized their laws, although there has been some variability between states

Ethical setting Status of the fetus with regard to

personhood

Conflict of rights

Conflict of duties

Who is the patient?

Relevance of fetal abnormality

Late TOP Originally performed for maternal

medical indications

Late diagnosis – psychosocial factors

Fetal abnormalities

Current roles for the psychiatristEARLY TOP Counselling a patient with an unwanted

pregnancy

Expertise in the area of mental illness and pregnancy

Supporting a patient after diagnosis of

fetal abnormality

Current roles for the psychiatristLate TOP Similar role – Late TOP more emotionally

challenging

Complex medical decision (cf organ transplants)

“Clinical ethicist”

Staff support

Problems A valid contribution to make?

Double agent role

Abuse of power

Diminishment of profession

A valid contribution to make? Difficult to predict suicide No good evidence that carrying a

pregnancy to term will be more harmful than TOP

Patients are assumed to be competent and able to make treatment decisions

Danger of over-identification with patient’s plight

Double agent problem Arises from conflicting responsibilities,

loyalties and goals Psychiatrists are frequently responsible to

parties other than the patient (hospital, family, community, justice system, insurance companies, social security system)

Conflict of interest

Abuse of power Power arises from coercion powers, from the

fact of being a physician and from patient vulnerability

Society gives psychiatrists a role in non-psychiatric decisions based on mental function

Pressure to manipulate diagnosis

Agents of social control: Nazi Germany and former Soviet Union

Diminishment of profession What is psychiatry?

Historical assumption of trust

Fidelity as an important virtue Essential for someone to become a patient Cannot be maintained if acting for another

party

Conclusions Decision to perform a late termination of

pregnancy is a difficult and complex one

Clarity needed regarding society’s views

Need for legal reform?

Psychiatry as a profession needs to consider its position

THE END