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Medical and bioethical issues in abortion
1. By Maria Theresa R. Termulo, M.D.
August 24, 2013
Medical and Bioethical Issues
in Abortion
2. The Atheist Doctor
(http://theatheistdoc.ph)
De La Salle University, Taft-
Manila (B.S. Biology)
University of Santo Tomas
Faculty of Medicine and
Surgery
Licensed Physician since
August 2005
Victor R. Potenciano Medical
Center
Internship (2004-2005)
Internal Medicine Residency
Training (2008-2011)
Emergency Room Officer
(May 2012 – present)
Mandaluyong City Medical
Center
In-house Internist (May
2012 – present)
5. OBJECTIVE
1. To impart medical knowledge about abortion, in
order for you to make an informed choice.
2. To create informed awareness on the reality of
abortion in the Philippines
7. INTRODUCTION
Unintended pregnancy is common in the
Philippines, and it often leads to abortion
Six in 10 Filipino women say they have
experienced an unintended pregnancy at some
point in their lives.
About 1.43 million pregnancies each year—nearly
half of all pregnancies in the Philippines—are
unintended.
8. Nearly half of pregnancies each year end in an induced abortion or
an unplanned birth
Juarez F et al., The incidence of induced abortion in the
Philippines: current level and recent trends, International
Family Planning Perspectives, 2005, 31(3):140–149.
9. In 2008, an estimated 560,000 abortions were performed
in the Philippines, and 1,000 women lost their lives to such
procedures while as many as 90,000 were hospitalized for
complications
The Philippines has one of the highest maternal mortality
ratios in the Western Pacific Region, as defined by the
WHO, at 230 maternal deaths per 100,000 live births
.
Center For Reproductive Rights. FORSAKEN LIVES:
The Harmful Impact of the Philippine
Criminal Abortion Ban. 2010
10. Reasons Why Filipino Women
Attempt Abortion
Inability to afford the economic cost of raising a
child
Pregnancy resulted from forced sex
They have enough children
Pregnancy occurred too soon after the last one
Feared pregnancy will put their health at risk
Feared that their partners do not want the
pregnancy
Older patients: they have too many children
Younger patients: conflict with school; consider
themselves too young to have a baby
Singh S et al., Unintended Pregnancy and Induced
Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher
Institute, 2006.
11. Profile of Patients Who Have
Abortions
Is the Majority Married or Unmarried?
12.
13. Profile of Patients Who Have
Abortions
Is the Majority Religious or Non-Religious?
22. Methods employed by Filipino
Women to attempt abortion
Surgery or ―operation‖
Dilatation and curettage
Manual vacuum
aspiration (MVA)
Misoprostol
Hormonal pills
Injectable hormonal
contraceptive
Insertion of a catheter
into the cervix
Insertion of other objects
into the cervix
Massage
Aspirin or other
medications
Eating or drinking
traditional medicine/herbs
Drinking alcohol
Fasting
Climbing a tree
Jumping
Exercising
Singh S et al., Unintended Pregnancy and
Induced Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher Institute, 2006.
29. CONCEPTION
• Fertilization
• Zygote’s
genetic
makeup is
complete, incl
uding sex
• In about 5-10
days, dividing
very fast into
many cells
and
eventually will
pass through
fallopian tube
to attach to
the uterine
wall
30. 4 Weeks
• Embryo starts
to form
structures
that will
eventually
become the
face and neck
• Heart, blood
vessels, lungs
, liver, stomac
h developing
• Home
pregnancy
test kits will
usually turn
positive
31. 8 Weeks
• Half an inch
in size
• Eyelids and
ears forming
• Arms and
legs
• Fingers and
toes become
distinct
• Tissue forms
that develops
into the
vertebra and
some other
bones.
• Rudimentary
blood moves
through the
main vessels
32. 12 Weeks
• 2 inches long
• Since Week
10 of
gestation, the
embryo is now
known as
―fetus‖
• Starts own
movements
• Fetal
heartbeat
(using
doppler)
• Intestines
rotate
• Genitals
appear well-
differentiated
• All essential
organs have
33. 16 Weeks
• 4.3 to 4.6
inches long
• Heart and
blood vessels
are fully
formed
• Fingerprints
• Lanugo
• More muscle
tissue and
bones have
developed,
and the
bones
become
harder.
34. 20 Weeks
• 6 inches long
• Top of the
uterus is at
the level of
the belly
button
• ―quickening‖
• suck
thumb, yawn,
stretch
• hearing
• Gender is
clearly seen
at ultrasound
35. 24 Weeks
• Responds to
sounds by
moving or
increasing
pulse
• Lanugo hair
covers entire
body.
• Jerking
motions or
hiccups
• fetal
heartbeat can
be heard with
a stethoscope
• Bone marrow
begins to
make blood
cells
36. 28 Weeks
• Baby weighs
2 pounds
• Lung maturity
begins (air
sacs)
• hand and
startle reflex
• nervous
system is
developed
enough to
control some
body
functions
• Rapid brain
development
37. 36 Weeks
• Brain rapidly
developing
• Lungs fully
developed
• rapid increase
in the amount
of body fat
occurs
• Head
positioned
down in the
pelvis
• bones are
fully
developed, bu
t still soft and
pliable
39. Threatened Abortion
a pregnancy is complicated by vaginal bleeding
before the 20th week.
Pain may not be a prominent feature
Vaginal examination at this stage usually reveals
a closed cervix
25% to 50% of threatened abortion eventually
result in loss of the pregnancy.
40. Inevitable Abortion
vaginal bleeding and cramp-like lower abdominal
pain.
The cervix is frequently partially dilated, attesting
to the inevitability of the process
41. Incomplete Abortion
vaginal bleeding, cramp-like pain, and cervical
dilatation with some passage of products of
conception
42. Complete Abortion
passage of all the products of conception
the uterine contractions and bleeding abate
the cervix closes
uterus is smaller than the period of amenorrhea
would suggest
symptoms of pregnancy are no longer present
the pregnancy test becomes negative
49. Medical Abortion (Early
Pregnancy)
Mifepristone plus Misoprostol
Mifepristone, 100–600 mg orally, followed by:
Misoprostol, 400 g orally or 800 g vaginally in 6–72
hr
Methotrexate plus Misoprostol
Methotrexate, 50 mg/m2 intramuscularly or orally,
followed by:
Misoprostol, 800 g vaginally in 3–7 days; repeated
if needed 1 wk after methotrexate initially given
52. Medical Issues
When is it allowed to happen?
Which takes precedence: Mother or Baby? Is
consent of partner required?
Pregnancies as a result of rape
Can abortion be offered to mentally-ill patients?
Patients dying due to Septic Abortion
(unsuccessful/successful attempt at abortion)
53. When is it allowed to happen?
Therapeutic abortion
heart disease after cardiac decompensation
advanced hypertensive vascular disease
invasive carcinoma of the cervix
54. Abortion is permitted in nearly every country at
least to save the life of the pregnant woman
(―Defense of necessity‖) - allows a doctor, for
example, to justify breaking the law by performing
an abortion because the action saved a woman’s
life.
Center for Reproductive Rights, The World’s Abortion Laws(2009).
55. Nearly half of all countries permit abortion in
cases of rape or incest, in addition to other
grounds, though procedural requirements in
these cases may vary.
Many of the same countries permit abortion in
cases of fetal impairment
Center for Reproductive Rights, The World’s Abortion Laws(2009).
56. More than one-third of all countries allow abortion
on economic or social grounds, such as income
level, age, marital status, and number of children.
More than 50 countries, with nearly 40 percent of
the world’s population, permit abortion for any
reason, though most limit the period during which
women can readily access the procedure.
Center for Reproductive Rights, The World’s Abortion Laws(2009).
57. Countries that permit abortion to
save a mother’s life (in Asia)
Afghanista
n
Banglades
h
Bhutan –
R/I/+
Indonesia
Iran – F
Iraq
Laos
Lebanon
Myanmar
Oman
Philippines
Sri Lanka
Syria
United
Arab
Emirates –
SA/PA
West Bank
&
Gaza Strip
Yemen
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion
58. Countries that permit abortion to
protect mother’s life and health(in
Asia)
Jordan
Kuwait –
SA/PA/F
Maldives –
SA
Pakistan
Qatar – F
South
Korea –
SA/R/I/F
Saudi
Arabia –
SA/PA
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion
59. Countries that permit abortion to protect
mother’s life and physical health, as well as
mental health(in Asia)
Israel –
R/I/F/+
Malaysia
Thailand –
R/F
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion
60. Countries that permit abortion to protect
mother’s life and physical health, as well as
mental health and based on socio-economic
background(in Asia)
India –
PA/R/F
Japan –
SA
Taiwan –
SA/PA/I/F
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion
61. Countries that permit abortion without restriction
as to reason (during first trimester)
Armenia
Azerbaijan
Bahrain
Cambodia –
GL 14 weeks
China – S/GL-
none
North Korea –
GL-none
Georgia – PA
Kazakhstan
Kyrgyzstan
Mongolia
Nepal – S
Singapore –
GL 24 weeks
Tajikistan
Turkey –
SA/PA/GL
10 weeks
Turkmenistan
Uzbekistan
Vietnam –
GL-none
Note:
R – Abortion permitted in cases of rape
I – Abortion permitted in cases of
incest
F – Abortion permitted in cases of fetal
impairment
SA – Spousal authorization required
PA – Parental authorization/notification
required
U – Law unclear
GL – Gestational limit
S – Sex-selective abortion prohibited
+ – Abortion permitted on additional
enumerated grounds relating to such
factors as the woman’s age or capacity
to care for a
Child
Source: Center for Reproductive
Rights, World’s Abortion Laws
(2009).
Abortion
62. Bioethical Issues
Moral status of a fetus
Is the fetus a person? At what stage in its
development does it becomes a person?
Rights of the Pregnant Patient
Does the pregnant woman have the right to decide
if she is going to carry the baby to term or not?
Principle of Double Effect
64. Possible Criteria of Personhood
Conceived by humans
Genetic structure
Physical resemblance
Presence of a soul
Viability
65. Judith Jarvis Thomson and Jane
English
―Even if the fetus is a person, abortion may be
morally justified‖
66.
67. Limitations of Thomson’s analogy
Only covers cases of rape.
The violinist is not someone to whom one is
related, even potentially.
68. Jane English’s Revisions
Imagine that you go out at night, knowing that you
might be rendered unconscious and hooked up to
the violinist.
You would still, according to English, be entitled
to unhook
yourself.
This case is more closely analogous to
conventional cases of unwanted pregnancies.
69. Principle of Double Effect
Four Conditions must be met:
the action itself must be either morally good or at
least morally neutral (nature-of-the-act condition);
the bad consequences must not be intended (right-
intention condition);
the good consequences cannot be the direct causal
result of the bad consequences (means-end
condition);
the good consequences must be proportionate to
the bad consequences (proportionality condition).
71. Personal and Professional
Experience Related to Abortion
As a Medical Clerk and Intern
In UST
Some OB-Gyne Residents scolding patients, threatening
report of incident to the police
OB-Pedia projects: Mothers’ classes
In Fabella
Patients treated a little more kindly but still with some
instances of ―rudeness‖ from health-care staff
OB doctors educating mothers
In VRP
72. Six in 10 of a small sample of providers interviewed
in 1999 reported that although they believe women
who have had abortions should receive medical
attention, the women ―are criminals and should be
punished.‖
Tandigan E et al., Assessing Health Workers’ Attitudes and Practices on Abortion
in Selected Health Facilities in the Province of Nueva Vizcaya, Manila, Philippines:
EngenderHealth and United Nations Population Fund, 1999
75. Inform loved ones/people you trust most
SEEK PHYSICIAN CONSULT PERSONALLY
If you attempted abortion, STILL SEEK HELP!
76. References/Recommended
Readings
Center For Reproductive Rights. FORSAKEN LIVES:
The Harmful Impact of the Philippine Criminal
Abortion Ban. 2010.
Singh S et al., Unintended Pregnancy and Induced
Abortion in the Philippines: Causes and
Consequences, New York: Guttmacher
Institute, 2006.
Judith Jarvis Thomson, "Abortion," The Boston
Review, Vol. XX, No. 3, (Jan 1994/Dec 1995). Full text
& replies.
Fetal Development Picture Slideshow. WebMD.
http://www.webmd.com/baby/ss/slideshow-fetal-
development.
Fetal Development. Medline Plus.
http://www.nlm.nih.gov/medlineplus/ency/article/0023