The current series of Call the Midwife is set in 1966. We dispensed with World Cup fever in about half an episode and are now focussing on other things in the news that year. The most significant of these, from a midwifery perspective, was David Steel’s Abortion Reform Bill which was then going through Parliament.
In this week’s episode, Trixie is filled with compassion for a woman who finds herself pregnant with a fifth child while living in squalid conditions with an unemployed, abusive husband. Ever passionate and outspoken, Trixie ends up on the radio arguing for the new law against a couple of pompous, patronising older men.
‘If this Bill is approved‘, argues one, ‘then doctors will feel pressured to use it, and the floodgates will open.’
‘Does [the Bill] not give doctors the right to determine which women may or may not be suitable to have children?” the other suggests.
‘Yes, what happens if society ‘doesn’t approve of a certain type of woman, or of how they live? Will doctors be encouraged to terminate these pregnancies?” asks the first.
‘No of course not!” Trixie bursts out, ‘No doctor would subject a patient to a medical procedure that carries risks unless they felt it was necessary. No doctor would consider termination lightly. ‘It’s very often the last resort. These changes are being proposed to allow doctors to use their professional discretion when faced with women in desperate straits, and to stop them being castigated as criminals. Most babies are loved and wanted, but there are women who find themselves in situations that are harmful to their health and to their sanity – they simply cannot cope. They are living in dreadful social conditions, with no hope, and no money. How can that be beneficial to any child?‘
‘Then change the conditions,” one of the men responds, ‘Give them better housing, more jobs, allow them to bring their children up in safety.’
‘Why ‘can’t we do both?‘ Trixie asks. ‘All I know is what ‘I’ve seen – women bleeding to death in dirty rooms up back alleys. Women desperate to avoid the stigma of an unplanned baby. … I know that this is a question of conscience, and my conscience tells me that this Bill should pass.‘
Trixie’s passion and compassion are compelling, and the stories the programme has told do indeed pull at the heartstrings. But it struck me that there are many parallels between this push for legalising abortion and the one we are seeing today for the legalisation of assisted suicide. So what lessons can we learn?
- The desperate stories aren’t the full story.
- Doctors are deciding which kinds of lives are worth living.
- ‘Doing both’ doesn’t reduce the demand.
- Doctors are pressured to use the freedoms they have been given, and the floodgates have opened.
1) The desperate stories aren’t the full story
Trixie herself knows that it is not only desperate women living in dire conditions at the end of their tether who seek abortions. Just a few episodes earlier, she observed an abortion in a private clinic performed on a woman who had the means to pay for such a service from a doctor who was willing to break the law and run a lucrative side business.
Part of the storyline there was about equality; Trixie was outraged that rich women could afford to have illegal terminations safely in sterile clinics while poor women were forced to resort to desperate measures. That is a conversation worth having. Assisted suicide is already available to those with the means, the connections and the know-how – Dr Henry Marsh told the nation on BBC Radio 5 Live earlier this month (recording available until 14 June) that he has got a ‘suicide kit’ ready for when he wishes to use it (which is perfectly legal), and a ‘medical friend’ who is willing to help end things if it doesn’t go to plan (which is not). Others can travel to clinics such as Dignitas to have their dying wishes fulfilled. Is it right that some parts of the population are able to access help to end their lives when others aren’t?
But Trixie entirely fails to mention this angle in her argument. Perhaps she doesn’t want to break the confidentiality of that clinic she worked in, or perhaps she simply knows that a heart-breaking story of desperation is more compelling than one about equality. The episode would have held more integrity if one of the characters had challenged her on this point, though. ‘Isn’t it true that this isn’t just about a few desperate women seeking help as a last resort? Aren’t there many more women who would take advantage of it if it was legal?’ History tells us the answer, and there is no reason to think that assisted suicide would be any different.
2) Doctors are deciding which kinds of lives are worth living
The men involved in the Call the Midwife interview feared that doctors would discriminate against lifestyles and poverty levels and women thought ‘unsuitable’ to be mothers. As far as I am aware, there is no evidence in the UK of this happening systematically, though abortion rates rise steadily in line with Indices of Multiple Deprivation (IMD) – meaning the more deprived a woman is, the more likely she is to have an abortion – and Black women make up only around 3.3 per cent of the population but account for eight per cent of abortions. Are doctors pressuring these women into having abortions? This is a hugely difficult and sensitive issue, but wherever the pressure is coming from, it does seem that some demographics are more likely to undergo abortions than others.
One thing we do know, however, is that doctors and other medical staff routinely offer abortions – often multiple times throughout the pregnancy – to women whose fetuses have been diagnosed with Down syndrome and other non-life-threatening conditions. ‘We were offered 15 terminations,’ one mother told the BBC recently, ‘even though we made it really clear that it wasn’t an option for us, but they really seemed to push and really seemed to want us to terminate.’
If medical teams are already deciding which sort of people shouldn’t be given the chance of life in this context, why would we expect them to be any different at the end of life? And might other life circumstances be a factor in pushing people to seek assistance in dying as they seem to be in seeking an abortion?
3) ‘Doing both’ doesn’t reduce the demand
At the recent inaugural meeting of the APPG for Dying Well, Andrew Mitchell MP asked why we can’t both change the law on assisted dying and invest further in palliative care. Again, the abortion statistics can point us towards the answer. In 2019 there were 207,384 abortions in England and Wales, up from 23,641 in 1968. In that time, living standards have improved considerably. There are still people living in deep poverty, of course, but the kind of squalor and desperation pictured across vast swathes of East London in Call the Midwife is, thankfully, a thing of the past. Living conditions have improved. Women do have access to much more help and support. Yet abortion continues to rise, and in fact, has been rising sharply since 2016, even though the unemployment rate has been falling steadily since 2013.
Improving conditions seems to make a negligible difference to the abortion rate. The biggest factor appears to be normalisation. After reaching nearly 160,000 in 1972, the rate of abortions dropped to a low of 129,673 in 1976 before rising to resume its 160,000+ level in 1980, never to dip below that number again. Once it became accepted, the numbers remained high and have, for the most part, only risen year on year.
Let’s ensure we improve access to and information about palliative care first – as these are the areas of greatest need – and work to improve the quality of that already available even further. We can either reduce the demand or give in to it; trying to do both simply doesn’t work.
4) Doctors are pressured to use the freedoms they have been given, and the floodgates have opened
Over 200,000 abortions per year is a flood, by anyone’s standards. Evidence such as that of the ‘mystery client’ investigation carried out last year by Christian Concern suggests that abortion providers such as BPAS are familiar with approving abortions for ‘any reason other than the sex of the baby’, simply ‘attaching’ women’s reasons to the legal reason that fits it the best. This is most commonly (98% of the time) Ground C, which states:
That the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
The BPAS call handler in the conversation linked above seems to have decided that ‘it sounds like emotionally it’s not the right time’ for her caller to be pregnant constitutes significant injury to the woman’s physical or mental health. The floodgates are open.
In terms of pressure on doctors, the antics of Westminster around giving the Northern Ireland Secretary new rights to force Northern Ireland to begin commissioning abortion services certainly look like a vast weight of legislative pressure to perform abortions, rather than allowing doctors to use their discretion in extreme cases. The repeated onslaughts on doctors’ conscience rights (the latest being this one by the World Medical Association) and the push to ‘normalise’ abortion still further constitute pressure on medical teams to provide abortions or ensure women have sufficient information to be able to access them.
Would assisted suicide providers not quickly follow suit, interpreting ‘I’m fed up with mowing the lawn’ as meeting a legal criterion for enduring unbearable suffering, for example? Would doctors not feel pressure from their budgetary committees to begin referring more people for a quick and easy death rather than long, expensive disease management and palliative care?
Trixie’s passion for the legalisation of abortion is portrayed as an entirely positive thing in Call the Midwife. Even the nuns had only a few qualms about her position (and in particular about her speaking out publicly about it). She is warm and compassionate, and she has changed the minds of all those around her who once thought every life, from its earliest moments to its last, was precious and worth fighting for. We need to be alert to these tugs on our heartstrings and look unflinchingly at the truths behind the emotions. The legalisation of abortion has given us a template for what we are likely to see if assisted suicide and/or euthanasia were to be legalised here. Let us learn the lessons history longs to teach us.
A translation of this blog appears on the website of CMF’s sister organisation, AEMC in Portugal.