‘Abortion Games’: The Negotiation of Termination Decisions in Post‐1967 Britain
2018; Wiley; Volume: 104; Issue: 359 Linguagem: Inglês
10.1111/1468-229x.12729
ISSN1468-229X
Autores Tópico(s)Historical Psychiatry and Medical Practices
ResumoThe 1967 Abortion Act placed the responsibility for determining the appropriate grounds for a termination with two medical practitioners. This assessment, to be made ‘in good faith’, hinged on the doctor's interpretation of the wording of the Act and how widely they defined the potential ‘risks’ of continued pregnancy.1 This responsibility could be troubling for doctors, who were being asked to use their medical expertise to determine what many considered to be a non-medical matter. Doctors varied, both between and within localities, not only in their interpretation of the terms of the Act but also in their ethical and personal attitudes to abortion and to women who might find themselves in this situation. While some doctors adopted a more liberal policy, based on the woman's wishes, others felt a firm conviction to interrogate the patient's reasons and perhaps persuade her to take a different course of action. This article focuses on the relationship between doctors and women seeking abortions following the passage of this Act, which placed doctors in a position of having to determine which cases were appropriate and deserving, creating a situation which some have argued facilitated performance and ‘game playing’.2 The individuals involved in these decision-making processes may have had differing perspectives or objectives, and while these were sometimes overt it was often mooted by both doctors and reproductive rights campaigners that elements of concealed strategizing or performance might be present in these negotiations. Instead of adopting outright persuasion, doctors could distance themselves from the decision-making process; for instance, general practitioners could refer their patient without including a recommendation either way, or make the referral to a gynaecologist who was known to be either particularly liberal or particularly stringent, making the decision a somewhat foregone conclusion. They could delay appointments, or approve the procedure only if sterilization was also agreed to, in order to put the woman off or encourage her to look elsewhere.3 Women seeking terminations, on the other hand, were often aware that certain circumstances or scenarios were more likely to gain sympathy than others, and might tailor their stated reasons for seeking termination accordingly. A mother struggling with multiple children already, or a ‘nice girl’ in unfortunate circumstances who exhibited remorse, were often looked upon with more understanding than someone who had apparently failed to demonstrate responsibility by using contraception effectively, and particularly someone who required more than one termination.4 This knowledge might encourage the presentation of particular narratives, and in turn cause doctors to be wary of being told something that fitted too closely to what they expected or needed to hear. Contemporary studies of abortion practice showed clearly that this process of negotiation and assessment varied significantly, contributing to divergent abortion figures and experiences of women seeking terminations both within and between regions across Britain. The way the medical interview functioned in practice will be explored through an analysis of medical and sociological studies of abortion practice in the first two decades the Act was in operation, and through the testimonies of healthcare professionals involved in decision-making and of women seeking terminations. Despite sustained and increasing criticism, and numerous attempts to change the law over the past five decades, the need for two doctors to certify appropriate grounds has remained in place for fifty years. Though the legal situation has not changed, medical and lay perceptions of the purpose and function of the medical interview have developed considerably across this time, and the degree to which doctor–patient interactions and the making of termination decisions has changed in practice as a result will be considered. Under the terms of the Act, in order to certify grounds for termination two medical practitioners have to agree in good faith that continuing the pregnancy would involve greater risk of ‘injury to the physical or mental health of the pregnant women or any existing children of her family’, or that there is ‘substantial risk’ of serious foetal anomaly. In making this judgement they can take into account ‘the pregnant woman's actual or reasonably foreseeable environment’.5 In most cases the two doctors would be the patient's general practitioner and the consultant gynaecologist who would undertake the termination, but women might also be referred to and assessed by other hospital doctors, psychiatrists, family planning doctors, medical social workers, and pregnancy advisory service doctors and counsellors, in an extended ‘interviewing process’. The Act was commended by many doctors at the time it was passed for being ‘permissive’ and yet ‘in no way obligatory’, due to its provision of a conscientious objection clause which ensured that no doctors would be forced to undertake the operation, except to save a pregnant woman's life.6 While the terms of the Act were ‘deliberately vague’, leaving considerable scope for interpretation and discretion, it stopped well short of abortion ‘on demand’ in placing the responsibility for the decision definitively with the medical profession and not the pregnant woman.7 The Act was passed primarily for public health reasons, to halt criminal abortions and provide doctors with legal protection from prosecution under certain circumstances, and control the provision of abortion by bringing women ‘out of the backstreets and into contact with their GPs’.8 In fact, one aim or desired consequence of the Act was to reduce numbers of terminations through promoting and legitimating contact between women experiencing crisis pregnancy and a reasoned and reassuring doctor. During the debates on his Bill, David Steel asserted that ‘in many cases’ the effect of its introduction would be fewer abortions, since being able freely to consult the family doctor could provide reassurance and ‘guidance’ to a patient who would otherwise seek a backstreet abortion, helping and encouraging her to continue with the pregnancy instead.9 In the early years of the Act, some compared the decision to place the responsibility with two doctors favourably with systems operating in other countries, such as the Scandinavian ‘tribunal procedure’ which reportedly resulted in significant delays and discouraged women from seeking legal abortion.10 Another benefit noted by some was that being granted a termination by two doctors might validate women's own decisions, positioning their reasons as ‘socially acceptable’ and therefore lessening ‘the guilt and self-recrimination that a few women feel’.11 Writing in 1971, consultant psychiatrist Hordern felt that ‘many women find comfort in realising that it is a considered decision, taken by two independent medical practitioners in light of the total situation, and that it is not being performed merely because they (the patients) are worried or are evading their responsibilities’.12 Such a construction could imply that a decision taken by a pregnant woman would not be a ‘considered’ or responsible one, and this indeed follows the binary model laid down in the Act. In putting the decision in the hands of doctors, the Act created a situation where doctors were characterized as responsible and rational actors, while pregnant women were by extension irresponsible and irrational, insufficiently ‘stable or rational to make important reproductive decisions’.13 While some doctors supported a woman's right to choose and prioritised her wishes when making their assessment, others felt strongly that she was in need of an expert to assess and diagnose what was best in her particular situation. Some doubted that a woman in such a ‘predicament’ would understand ‘what was in her best interest’ and considered that a woman's wishes might be different from her ‘needs’; fearing that ‘by making abortion too readily available we do little but relieve the patient's immediate suffering for a short time and thus do her no real service’.14 However, from the earliest days of the Act some doctors expressed concern at the responsibility that had been placed on their shoulders, believing that the Act offered confusion as well as flexibility, and potentially created difficulties for doctors and for the doctor–patient relationship. Davis and Davidson have argued that policy-makers had deflected responsibility on to the medical profession, many of whom accepted the resulting ‘medicalization’ of abortion reluctantly, at least at first.15 Consultant gynaecologists, who had to perform the termination and take legal responsibility for it, might find deciding whether or not to do so a grave and ‘onerous task’ that had nonetheless to be taken quickly in an ‘emotion-charged situation’.16 Some feared the pressure of trying to make an evaluation ‘while under considerable pressure in terms of time, stress, and emotional atmosphere, yet at the same time giving the patient the feeling that the investigation is disinterested and thorough’.17 Some felt that their medical training had not prepared them for making decisions of this nature, noting that the Act gave the medical profession ‘considerable freedom to decide’ but only ‘vague criteria’ to follow, meaning that doctors were ‘thrown into an unknown sea’ with ‘only their own personalities, experiences, codes of ethics, religious scruples’ to guide them.18 In 1971, the consultant psychiatrist Ingram wrote a piece for The Lancet titled ‘Abortion Games’, in which he applied Eric Berne's ‘game theory’ to the interactions and decision-making processes involved in determining access to abortion.19 Ingram expressed a deep discomfort with being ‘obliged to give opinions’ on matters he considered ‘non-medical’ and felt that the ‘ambiguity’ of the Act disturbed both doctors and patients, leading to ‘a fear of decision-making and to game playing’.20 In his article, Ingram outlined the concealed motives behind these interactions and potential strategies available to all actors involved. General practitioners could distance themselves from decision-making by referring the woman in question to another doctor without advocating for one outcome or another, or they could appear to do so but pass the decision to a gynaecologist who had a particular reputation for either approving or rejecting termination requests. Thus they could conceal their judgement and avoid a confrontation with the patient. Gynaecologists might delay appointments until the pregnancy was too advanced to terminate (a game he called ‘Waiting List’), or might agree to undertake the procedure only if the patient also agreed to a sterilization.21 In having to navigate these various doctor ‘games’, Ingram likened the process of obtaining an abortion from the woman's perspective to an ‘obstacle race’. In a similar fashion, Lafitte of the British Pregnancy Advisory Service spoke of it as an ‘abortion hurdle race’, where the hurdles women had to overcome were first the GP, and then the consultant gynaecologist.22 Tensions were possible between doctors and women seeking abortions if their interpretations of the situation did not correspond. The potential for this could lead to a wariness of the others’ motives, and create a situation where it might in fact be logical to conceal one's strategy and put on a performance, in order to achieve the desired outcome. Ingram points to logical reasoning that might encourage a woman to do this, noting that ‘honesty may not be rewarded’; ‘The intelligent woman who weighs her life situation and decides rationally and calmly that termination is necessary – that is, plays no games – is less likely to succeed than her more emotional sister who chooses to play “Psychiatric case” and produce the symptoms that the doctor seeks to justify termination.’23 Therefore the Act and the interactions it proscribes could become a self-fulfilling prophesy, as women might in fact be incentivized to present as irrational and disordered in order to be granted an abortion. While doctors did not necessarily agree with Ingram,24 some echoed his findings, noting that although ‘he approached the subject in a lighthearted manner, his analysis of the way by which the doctor tries to avoid making positive decisions about abortion are nonetheless true’.25 There are numerous other examples of doctors referring to the legally necessary medical interview as a ‘pretence’ or ‘charade’, because the pregnant woman is required to perform a specific role in order to meet the recognized legal grounds for termination. The gynaecologist Peter Diggory wrote of it in these terms in 1975, feeling that it was ‘humiliating and degrading’ for a woman to have to ‘exaggerate her distress’ in order to demonstrate adequate grounds for abortion: ‘if I'm faced with a girl wanting an abortion why do I have to test how distressed she is? All I get is a charade played out for me.’26 The ‘games’ or scenarios set out by Ingram and others can be identified again and again in the various studies of abortion practice which proliferated in the decades following the Act's introduction, no doubt due to its immediate and ongoing controversy. These highlight the significance of women's interactions with their doctors and indicate how much control the doctor had over the situation, potentially dominating the interaction and controlling the outcome. They also give useful indications of the criteria doctors used in decision-making, allowing an examination of which categories of patient were viewed as sympathetic or alternatively problematic. While certain trends can be clearly identified, ultimately the scope for individual interpretation by doctors resulted in a high degree of variability. Some did not feel the need to exert their own views or judgements by adopting persuasive tactics; however, as Jeffrey Weeks has noted, others were ‘far from being neutral servants of their patients’.27 Doctors had a significant impact on the outcome and experiences of patients seeking terminations, even when they did not overtly engage in persuasion. Sally Sheldon notes that even a kind and sympathetic doctor might ‘deploy power’ over the pregnant woman by ‘influencing her course of action, rather than facilitating her arrival at her own decision’ and that the system of legal regulation inscribed by the Act left her ‘in a particularly weak position to counteract the exercise of such influence’.28 Sally Macintyre's 1970s study of single and pregnant women in Scotland illustrates how clearly the attitudes and advice of doctors could set the parameters of the medical interview, and therefore the options open to young pregnant women. Only half the women interviewed knew without their doctor mentioning it that legal termination was an option, which is significant because only two of the GPs interviewed reported that they discussed all the available options including termination.29 This placed the onus on women to introduce the discussion. The Lane Committee on the Working of the Abortion Act (1971–4) found similarly that the option of termination was not necessarily discussed by GPs, and also that in particular young women were reluctant to approach their GPs in the first place, fearing negative attitudes, or perhaps that they might inform their family.30 Examples of outright persuasion were not uncommon. One of the doctors interviewed by Macintyre asserted that he was able to persuade the ‘majority of girls, those I've known since they were children’ to get married rather than abort, stating that although occasionally he did have patients ‘demanding termination’, ‘most can be talked out of it’.31 Other studies also found that a long-standing relationship with a doctor increased the likelihood that the patient could be persuaded; Tunnadine and Green found that in doctors who had a principled position either for or against termination, a ‘good doctor–patient relationship’ would lead to the ‘convertability of the patient to his ideas and she will carry out his instructions’.32 Allen's 1980s study suggested that young people were particularly vulnerable to being persuaded and ‘overpowered’ by doctors, and more mature patients sometimes felt they had to be very firm in their convictions in order to receive the outcome they wanted: ‘You know what little demi-gods doctors are … I felt I had the power to think for myself and not be influenced by him.’33 Many of the women Allen interviewed reported what they felt were attempts to override and intimidate them, one recounting that ‘He tried to make me feel like a six year-old with no opinions. Everything I said he twisted to have another meaning’ and in another case, ‘he was telling me my brain had made a mistake and I really wanted to keep the baby … He was using people who can't have children to get at me’.34 Half of the medical professionals that Allen interviewed reported that they would ‘attempt to dissuade a woman from abortion’, with GPs most likely to do so. Mirroring Ingram's concerns regarding referral, the GPs were likely to say that they would make a referral without supporting the request, and almost three quarters asserted that ‘there were circumstances in which they would’ dissuade women from abortion.35 As well as revealing great variation in the attitudes of doctors consulted, such studies identified particular trends in terms of which categories of patient were more likely to be accepted for termination, and which situations would elicit the most sympathy. Some doctors stated openly that ‘Sympathy – or lack of it – often determined the decision that was made’.36 While doctors referred to various practical criteria in coming to their decision, their assessment of these was subject to their own personal interpretation, and in some cases moral judgements. Numerous studies, including one in Wessex in 1980, found that though gynaecologists might refer to the same criteria when coming to a decision, the assessments they made as to the significance of these ‘were more of an individual matter’.37 Extremes of age and perceived intelligence usually merited consideration, as did the circumstances of conception and the pregnant woman's relationship with her sexual partner.38 Key topics raised by doctors in order to help make their decision included the possibility of alternatives to abortion (with marriage almost always raised with single women), the pregnant woman's home background, her education or career, her relationship with the putative father, and her sexual and contraceptive history. Women seeking terminations might be viewed and treated very differently by doctors according to their age, marital status and sexual history. In a 1982 Glasgow Herald article on barriers to treatment, a West End GP noted the difficulty he had in getting his patients approved at hospitals in the area: ‘Sometimes we manage to get a termination locally for women in their forties with large families but hardly ever for young unmarried girls.’39 Reaffirming this depiction, the Chairman of the gynaecological department at the local hospital stated that he found performing abortions ‘very distasteful’, and that ‘it is very difficult to terminate a pregnancy without good reason … I am not prepared to carry out the operation on a young unmarried woman just because it would be inconvenient for her to have the baby.’40 The plight of the young single woman is highlighted in numerous other studies from the 1970s and 1980s. Allen's large English study found ‘evidence of much less sympathy on the part of GPs towards the younger girls’, noting that married, divorced, widowed and separated women, and women with children, were much more likely to find their GPs helpful.41 Although married women appeared to be treated more sympathetically regardless, the most sympathy was reserved for those who were older and already had completed families.42 Hammil and Ingram's 1974 Glasgow study of abortion decisions found similarly that those recommended for termination tended to be older, married and to have children. When discussing the reasons doctors in their study did not agree with or approve terminations, they found that ‘the hard core of dissent is the single girl’ and that ‘this group provokes the most moralistic response from the profession’. Comparing their results with two earlier large-scale studies of termination practice conducted in London and Glasgow, they concluded that ‘whatever the degree of “liberality”, the core of refusals is formed by young single women pregnant for the first time’ and that this was the group that was deemed ‘most controversial’ and most often terminated privately.43 In order to navigate these particularly censorious judgements, then, young single women seeking terminations had to be particularly skilled in convincing doctors that they deserved an abortion. One of the most successful narratives according to Macintyre's study was that of ‘nice girl who made a mistake’, and in order to be classified as such doctors looked for ‘evidence that they had tried to use contraception, the account (if believed) that intercourse had taken place only once when drunk or under pressure, lack of evidence of promiscuity, and a demeanour of shame or regret in the consultation’.44 In such circumstances, a woman might be regarded as a good girl who had been unlucky or made a mistake – though marriage would be considered the more appropriate outcome if the relationship was sufficiently stable. On the other hand, if women were ‘believed to have slept only with casual acquaintances or strangers, they were seen as bad, promiscuous girls who did not deserve an abortion’.45 Similar language and practices are present in numerous studies, with one of Williams and Hindell's interviewees stating ‘I convinced the consultant I wasn't the type who sleeps around and deserves it.’46 Another group that faced particular difficulties, often overlapping with the first, were women with repeat unwanted pregnancies. These requests for termination often engendered the most judgemental responses. Hordern noted in 1971 that such cases were ‘difficult to assess’ but that repeated unplanned pregnancies were ‘not uncommon in the impulsive, the psychopathic and the unintelligent’.47 Allen noted numerous instances in her 1980s study of doctors warning women (particularly young women) who came in for abortions that they would not be seen a second time.48 Macintyre noted that the ‘reluctance of gynaecologists to terminate the pregnancies of single women who have had previous abortions is still often based on the concepts of deservingness and undeservingness’.49 Doctors seemed wary of inadvertently appearing to condone the use of abortion as contraception, which was how they tended to interpret repeat unwanted pregnancies. The case of a seventeen-year-old with learning difficulties living in an overcrowded home who, despite a supportive recommendation from her GP was refused a termination from a hospital consultant due to her having had a termination the previous year, was reported in the press. The hospital consultant had asserted that ‘abortion should not be used as a means of contraception’ and while her GP agreed he felt that this response lacked compassion and was inappropriate in these particular circumstances: ‘what the girl needed was immediate help and careful contraceptive education’.50 The consultant had made a judgement that she had shown a pattern of irresponsible behaviour, and therefore did not ‘deserve’ an abortion, and because of this she was denied help despite the difficulty of her situation. Perceived class and educational level often appeared significant in determining the likelihood of a woman obtaining an abortion, with the outcome being less likely ‘the lower their social class and the poorer their education’.51 Ingram noted two reasons that this was likely to be the case: firstly because similarity in class between doctor and patient encouraged empathy (‘Doctors sympathise more readily with the situation of those girls who might easily be their daughters’) and also because middle-class women tended to be ‘more knowledgeable about the law, better able to put their case across convincingly, and more skilled in doctor/patient games’.52 Hence they had less need to manipulate the medical interview, though they were also more likely to be able to do so convincingly if necessary. Many studies of abortion supported this contention. For instance, the Lane Committee found that working-class women were less likely to be accepted for termination and significantly more likely to face delays, noting that this difference could not be explained simply by their relative lack of recourse to private clinics.53 The needs of middle-class, educated women in skilled jobs were often seen to be more pressing than those of their sisters in semi-skilled and unskilled work.54 Hordern put this particularly starkly: ‘A woman of low socio-economic status in an unskilled or semi-skilled job may tolerate an unwanted pregnancy better than her counterpart in a responsible professional job; the latter, being higher in the social scale, has farther to fall.’55 The period of gestation could also be significant in decision-making, as a mitigating factor for any of the criteria discussed above. Numerous studies showed that doctors might agree to terminate for a greater range of reasons earlier on in the pregnancy, when the procedure was more straightforward. For instance, a 1974 investigation found ‘an informal agreement’ between gynaecologists and psychiatrists not to recommend termination after twelve weeks ‘except for compelling reasons’, and a 1980 study of gynaecologist attitudes in Wessex showed a dramatic decline in the willingness to terminate on socio-medical rather than strictly medical grounds after twelve weeks’ gestation.56 This indicates that women were much more likely to obtain an abortion if they presented early enough, and also illustrates how ‘Waiting List’ games, highlighted by Ingram, could be so powerful in influencing the outcome of termination decisions. The Lane Committee reported in 1974 that GPs ‘might have deliberately adopted delaying tactics in the hope that pregnancy would be accepted, or that it would be too late to get an abortion’.57 It could be difficult of course to determine whether appointments were delayed due to pressure on resources or doctor ambivalence, but women who faced delays often felt that this was deliberate.58 These studies clearly demonstrate evidence for Ingram's assertion that the medical interview necessitated by the Act appeared to encourage ‘game playing’ and performance from both doctors and women seeking terminations. Each might conceal the motives and reasoning behind their behaviours, and be suspicious of the words and actions of the other. Williams and Hindell found that the women in their study had both overt and covert reasons for seeking terminations; the overt reasons were the ‘respectable’ ones put forward to doctors ‘in order to obtain the abortion’, and were shaped by their expectations of what would be the most ‘acceptable’ reasons according to the medical profession and society at large. For example, their respondents ‘tended to believe that desertion by the father was a particularly acceptable reason … and a few confided that they had claimed desertion by the boyfriend in order to obtain the abortion when it was not true’.59 A well-documented way in which women could tailor their narratives better to fit doctor expectations of attempted ‘responsibility’ was through stories of contraceptive failure. Women's testimonies sometimes revealed explicitly how they might turn an everyday situation in which unwanted pregnancy might result (‘we'd run out of durex and I, at least, knew it was risky’) to a sympathetic story in which they felt they might be seen as more ‘deserving’: ‘The story I later recounted to various doctors was rather different as I soon learnt that this type of “irresponsibility” is just the thing that doctors think should be punished by unwilling childbearing. They react much better to sad tales of contraceptive failure.’60 This of course did not mean that women's stories would be believed. Doctors were aware that ‘ideas about “the type of case most likely to elicit sympathy from a GP” were prevalent in the lay community’ and were therefore wary of fabricated or embroidered stories that they felt might be designed to elicit sympathy. Macintyre found that several GPs in her study were ‘sceptical about claims of accidental or occasional intercourse’, believing these might be an ‘attempt to appear respectable and to blame the pregnancy on bad luck rather than bad behaviour’.61 These GPs based their assessment on ‘inferred moral character’ from the woman's sexual and contraceptive history, ‘how well they thought they knew’ the patient and ‘whether they regarded them as manipulative’.62 Several doctors appeared to view patient information on contraceptive history as likely to be fabricated; one study noted that the ‘evidence on contraceptives must be treated with reserve, for it is much easier to say that contraceptives were used and failed than to admit they were not used’ and another that ‘bad luck was a far less common occurrence than many of the women would have the doctor believe’.63 Tunnadine and Green felt that there was ‘considerable manipulation by both patient and doctor to gain the ascendency’ in these interactions, and that a patient in ‘desperate straits’ would go to ‘any lengths in furtherance of her goal’ and ‘will order, cajole, wheedle, or use any device which will suit her purpose’.64 In some circumstances doctors thought that women might ‘exert moral pressure’ by threatening suicide (sometimes described as ‘blackmail’
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