Longstanding Conscientious Refusal Assault to Undermine Swedish Abortion Policy Ended by European Court.

Ellinor Grimmark, one of the midwifes

For a number of years, two openly pro-life Swedish midwifes have been fronting for radical conservative US activist Christian organization Alliance Defending Freedom (ADF), to run a legal case against Swedish County Councils (that run the publicly funded healthcare system) in order to invalidate the Swedish model for freedom of conscience and conscientious objection in healthcare. In particular, the assault has been focused on the strong pro choice abortion legislation in Sweden, as both cases have been about trying to establish health professionals' (here midwifes) legal right to refuse to perform tasks related to abortion (everything from informing women about their rights and options to assist in the actual performance of a procedure). Since having an abortion at a public hospital is a positive right in Sweden, a midwife or other obstetric professional working in the public healthcare system can always be assigned to such duties, and it would be impossible to run the system is this was not the case. Therefore, a legal right to conscientious refusal in this area could very well be strategically exploited by anti-abortion propaganda ventures to undermine Swedish abortion policy.Read more and learn how this assault has now been stopped, and how other European countries may profit from that.

I blogged about this push, as well as the general issue of conscientious refusal in healthcare, in 2015. That post led to invitations to contribute to two separate special ethics journal issues on the topic, one of which describes the Swedish solution to conscientious refusal and is linked above. The other one, authored with Danish colleague Morten Ebbe Juul Nielsen, presents a general argument against the notion of conscientious refusal as a legal right required by the generally embraced legal human right to freedom of conscience. Simple put, as long as employment and choice of profession is voluntary, the latter freedom does not require a right to refuse particular work tasks.

The midwifes have been fronting the ADF campaign by running legal procedures complaining about religious discrimination, or breach of their freedom of religion, against (potential) employers who have denied them a right to refuse any dealings with abortion care, or refused employment after a declaration of such a right as a condition to accept employment. The case have been run through the Swedish legal system, and then, with one of the midwifes, Ellinor Grimmark, on to the European Court of Human Rights. Since 2014, bankrolling and legal councel has come from ADF, confirmed by its representative Robert Clarke.  Two days ago, the court delivered its decision to rule the application for the court to try her case to be inadmissible. In short, this means that the court cannot see any indication of discrimination or restriction the right to religious freedom in Grimmark's (and ADF's) writ. This has also been my impression from day 1 – what ADF and Grimmark have been asking for is not equal rights to others, but for special privilege. But, please, don't let me be the judge, read the decision for yourselves!

The court decision's most important implication is, however, not that the Swedish solution to the phenomenon of conscientious objection has been vidicated, and that its abortion policy has been safeguarded against radical religious conspiracy. It also means that all European countries can safely adopt the Swedish solution to conscientious refusal in healthcare, without fear of legal damage.
 

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Five Observations About Conscientious Objection in Health Care

This connects a little bit to a post not long ago, by my Canadian bioethics colleague Udo Schuklenk on his Ethx Blog, on the topic of conscientious objection in health care. The reason why I have started to think about this is that my country's rapidly shrinking Christian Democrat party has just elected itself a new leader – Ebba Busch Thor (see image to the left) – and the echo of the affirmative acclamation at the party's national congress had barely silenced before she made her first move to plug the many leaks of voters, members and sympathisers by declaring that health care staff should be given the legal right to conscientiously object to participate in the performance of legal abortion. This follows attempts in two public health care counties earlier this and the last year, initiated by single midwifes backed up by "pro-life" lobby organisations, to have the counties grant them such a legal right. Busch's Thor's move is obviously tagging onto these initiatives in an attempt to stop the flight of fundamentalist Christians from the party and mark a shift from the former party leaders more liberal and secular version of Christian Democrat ideology (whatever that is). At the same time, in both of the cases, the motions on behalf of the midwifes were denied by the county councils, albeit in one of them after some brief shuffling. In addition health care professional organisations (including the union of midwifes) have publicly stood up strongly against this sort of idea (see here, here, here), among these the Delegation for medical ethics of the Swedish Society of Medicine, of which I am an appointed member. More precisely, this delegation dismissed generally the notion of a right to conscientious objection for health care staff, no matter the procedure or background motivation. On top of that, given the very strong support of the liberal-feminist Swedish abortion legislation (in place since 1975 and giving all pregnant women a positive right to have an abortion performed by public health care, at barely no cost, up to the end of the 18th week of gestation, no questions asked), while Busch Thor's move might lure some of the lost fundamentalists back into the Christian Democrat pen, it will probably scare off even more of the more liberal and secular minded of the party's supporters. So far so good.

However, when discussing this issue with people in general and colleagues within both ethics and health care, and both in Sweden and internationally, I have encountered five very common confusions, which I will set out briefly in this post. If you feel yourself attracted to the notion of a legal right to conscientious objection, you may want to consider these before settling on a more precise opinion on the matter.

First, as in the case of Busch Thor's suggestion, there often seems to be an assumption that a legal right to refuse performing professional duties can be reserved for only some such duties and some professions. However, given basic principles of equality before the law, legal security and rule of law, this is an impossibility. I'm here assuming a situation where employers are granted a basic (civil) legal right to direct the content and form of the work supposed to be carried out by employees (as long as it is not illegal through some other statute), something that is the case in all jurisdictions I know of. This basic general principle implies, that if one category of employees are to be granted an exemption from the employee (civil) legal duty to follow employer instructions (or resign or be dismissed), the same exemption will have to hold for all other employees of other employers as well, as long as no special reasons tell otherwise. The same reasoning can be repeated for the sorts of tasks involved in a profession. In effect, if there is to be a legal right to conscientious objection by health care staff, this will by default have to affect all staff and all tasks, and it would moreover be a reason to grant similar rights to other professions. This, then, is the level at which any discussion of legal rights to conscientious objection will have to be conducted. For sure, there may then be arguments advanced to restrict the right to certain areas, but you cannot start the discussion by randomly cherry picking some professional area or task to discuss in isolation. The stand taken by the Delegation for medical ethics referred to above is based on this observation: you cannot just discuss conscientious objection in relation to an isolated health care procedure and profession, you have (at least) to discuss it regarding health care in general, including all procedures and categories of staff.

Second, there seems to be a repeated mistaken perception that if a legal right to conscientious objection is denied, the potential conscientious objectors will automatically be legally forced to perform the tasks to which they conscientiously object. Often this confusion is multi layered as it is cloaked in the form of an accusation of infringing the freedom of religion (by forcing people to act against their own faith). However, this is false in two ways. The fact that an employee doesn't have the legal right to decide what tasks his or her employment are to direct him or her to perform, is perfectly compatible with the fact that an employer exercises its right by finding room for the employee in the organisation where he or she will not be faced with the task to which he or she objects. Such accommodations are continuously and routinely arranged throughout the Swedish health care system, as it is – I presume – in other professional areas and jurisdictions. If that is not practically possible, most professional areas present opportunities of finding alternative employment more fitting to one's conscience. And if that proves difficult, there are a great many other areas to explore on the work market. That is, the conscientiously objecting employee have several alternatives to explore, so he or she is not forced in that way. Moreover, the fact that several of these alternatives may mean that he or she may have to change her work situation (including employer, pay, and so on) is no reason to regard his or her liberty to be restricted, as it is the responsibility of the employee his- or herself to have accepted employment where he or she may have to perform tasks to which he or she conscientiously object. With this falls also the claim that denial of a legal right to conscientious objection infringes religious freedom – the believer is and continues to be free to seek and obtain whatever work he or she chooses and no one has a right to stop that, but that does not imply that anyone has a duty to provide work accommodating anyone else's religious (or other) beliefs.

Third, to be denied a legal right to conscientious objection is perfectly compatible with the claim that it may be morally permissible or even required by a professional to refuse employer instructions – thus washing one's hand off whatever evil deed is being suggested. The particular confusion that this is not the case is very common among health care staff, not least doctors, in my experience. Presented with the issue, they often object that it is a frightening thought that one would have no right to refuse or even sabotage immoral instructions from employers – usually the case of Nazi Germany and recent examples of torture is brought up as examples. This, however, is to confuse two legal issues with each other and, in addition, these two with two (also confused) moral issues. Suppose, first, that your employer orders you to do something that is immoral and also illegal. In this case, you have a right to refuse, as the boundary of the employer's right to direct the content and form of the work has been overstepped – thus, you need no legal right to conscientious objection. Now, change the example, and assume that the immoral thing you are ordered to do is, in fact, legal. In this case, the employer's default right to order you to do this thing will hold, and you will be legally bound to comply (or find alternative solutions as indicated above under confusion no. 2). This, however, is perfectly compatible with the claim that you are morally permitted – indeed required! – to refuse the order, or, as said, even sabotage its execution. That is, you have a moral right to refuse a legal obligation, and this you will continue to have with or without a legal right to conscientious objection. In addition, denying such a legal right is also compatible with the claim that the legal provision of the ordering of the immoral task is morally unjustified, so the fact that you lack a legal right to conscientious objection will not undermine whatever moral reasons there are against the law (legally) obligating you to do it either. At the same time, both these moral reasons are, of course, separate – your reason to refuse the order is a reason for that, but the reason to have the law changed is not necessarily a reason for the former. My impression is that also this distinction is left unnoticed in debates on conscientious objection, and that it is often assumed that if there are moral reasons for changing a law, there is a moral reason to refuse its provisions. This, however, is an elementary fallacy. In any case – lack of a legal right to conscientious objection will not in any way undermine the moral reasons for or against single professional tasks or legal statutes relating to these.

Fourth, the moral right to refuse to do immoral things cannot be equated with a moral right to follow one's conscience. This is otherwise a surprisingly common confusion among religious advocates of the legal right to conscientious objection. What seems to be assumed is that a person's conscience will only tell this person certain things – in particular the moral messages embraced by the advocate of conscientious objection in question. But of course – and who should be more aware this than a devout follower of the Christian faith? – a person's conscience may relay messages from whatever source – spiritual or otherwise. Ergo, there is no moral right to follow one's conscience (and this seems to hold for whatever ethical theory is assumed). It may thus be suggested that many supporters of legal conscientious objection rights have simply confused these, with their perceived moral right to act on the morality they themselves embrace (a perception which may, of course, be mistaken).

Fifth, and finally, if there is a legal right to conscientious objection, this right will thus not be restricted to certain contents of consciences. This simple point seems to be almost always overlooked by conscientious objection advocates, and was made in the recent Swedish debate, by a medical doctor who satirically, in response to Busch Thor's declaration, went public to declare that he would henceforth refuse to treat religious people. Perhaps a bit ham-handed, this provocative move still illustrates one of the most basic problems with the idea of a legal right to conscientious objection: such a right cannot be restricted to any particular conscience. While it may provide a legal right for doctors and nurses honouring their professional ethos to refuse, e.g., participating in torture – should this have been made legal – or the right of those who find that objectionable to refuse participating in legalised assisted dying procedures or abortions, at the other end of the scale it would equally protect the rights of the vile, hateful racists or misogynist to refuse to assist in, e.g., the care of Jews or Roma people or "immigrants", or disabled, or others that such a person's conscience may tell him or her should not be included in public health care services. By implication, we may also imagine a hateful anti-religious doctor, who would be convinced that religious people should be denied privileges extended to others, and this person's right to execute this denial would then be protected by law – as would an imagined Josef Mengele leaving disabled babies to perish and die in the maternity ward where he works. So, while there is an often repeated rhetoric suggesting that a lack of a legal right to conscientious objection will open the door for Nazis and similar horrid figures to reign freely (dealt with above in confusion no. 3), it is in fact the very existence of such a legal right that opens this door – if there is a "Nazi argument" on this topic, it speaks against, not for, legal conscientious objection rights. On a grander scale, this illustrates, of course, that the upshot of a legal right to conscientious objection is nothing less than potential anarchy and arbitrariness – again the very opposite of what is required of the basic principles of the rule of law and legal security.

Luckily, for anyone conscientiously objecting to whatever task included in his or her work description, there are many easy solutions: Talk to your employer about changing role and, if that doesn't help, find a job where the task you object to is not on the menu. But first of all, do not take jobs where there are tasks to which you conscientiously object!

Special issue of Bioethics: Ethical Implications of New and Future Technical Developments in Prenatal Testing and Screening

One of  my core research fields over the years has been reproductive ethics, especially the ethics of genetic and reproductive technology. In my postdoc period, I published a study on the moral roots of prenatal diagnosis, followed by a number of further explorations of the ethics of reproductive technology, genetic testing and medical screening programmes in general. The last two years, this process has come full circle, due to new revolutionary technical developments regarding prenatal testing and related genetic analysis, and the last year or two, I have been busy presenting and discussing issues related to this several times with Swedish medical professional and medical ethical organisations and actors. In the spring of 2013, I was invited to present my views on this topic at a specially convened international symposium at the Brocher Foundation in Geneva, Switzerland. Out of that event now comes a full special issue on the ethical implications of new and future technical developments in prenatal testing and screening of the journal Bioethics, edited by Wybo Dondorp and Jan van Lith, of Maastricht and Leiden universities, respectively:

The content, of course, features a developed version of my talk at the Brocher meeting – A New Ethical Landscape of Prenatal Testing: Individualizing Choice to Serve Autonomy and Promote Public Health: A Radical Proposal – arguing that the technical advances of prenatal testing should herald the beginning of the end of of large societal prenatal screening programmes. But the issue also features a large number of other contributions from leading names in the field, e.g. Angus Clarke, Zuzana Deans, Ainsley Newson, Steve Wilkinson and Guido deWert, and the full table of content reads as follows:

EDITORIAL

1. Dynamics of Prenatal Screening: New Developments Challenging the Ethical Framework (pages ii–iv)Wybo Dondorp and Jan van Lith

PAPERS

1. 1. Prenatal Screening: Current Practice, New Developments, Ethical Challenges (pages 1–8)Antina de Jong, Idit Maya and Jan M.M. van Lith
      
      
   2. Psychological Aspects of Individualized Choice and Reproductive Autonomy in Prenatal Screening (pages 9–18)Jenny Hewison
   3. For Your Interest? The Ethical Acceptability of Using Non-Invasive Prenatal Testing to Test ‘Purely for Information’ (pages 19–25)Zuzana Deans, Angus J. Clarke and Ainsley J. Newson
   4. Prenatal Screening, Reproductive Choice, and Public Health (pages 26–35)Stephen Wilkinson
   5. A New Ethical Landscape of Prenatal Testing: Individualizing Choice to Serve Autonomy and Promote Public Health: A Radical Proposal (pages 36–45)Christian Munthe
   6. Prenatal Screening: An Ethical Agenda for the Near Future (pages 46–55)Antina de Jong and Guido M.W.R. de Wert
      
      
      
      

I and Other Philosophers/Bioethicists Criticise Richard Dawkins' Tweets and Statements on Abortion and Down Syndrome

So, I don't think anyone missed Richard Dawkins' recent ill-considered and inconsiderate tweet – in response to a personal, cautious reflection by a follower – that abortion of foetuses with Down Syndrome is morally obligatory, as well as the storm of outraged reactions to that and Dawkins' own retrospective apology and defence of his statements. Some reports are here, here, here and here. And Dawkins' own statement of apology and defence is here.

Now, in an article by Elizabeth Picciuto in The Daily Beast, a number of philosophers/bioethicists, among these myself, comment on Dawkins' statement from an intellectual point of view, as well as his attempt at formulating an intellectual and "logical" (a favourite adjective of Dr. Dawkins in his comments on the criticism) defence of it. Spoiler: it's not worth the paper it's written on and, in particular, it's peppered with logically invalid inferences.

On a personal note, I would like to add one thing to what's said in the article: Richard Dawkins' actions in this matter are especially peculiar in light of his former standing as Oxford professor of the public understanding of science. What he has done here is to promote widespread misunderstanding of bioethics, moral philosophy, as well as regarding the health science aspects of Down Syndrome and the rationale of liberal abortion legislation and prenatal diagnosis.

When is a Person's Religion A Personal Matter and When is it Not?

The following piece will not dig deep into the concept of religious belief and how it may or may not be different than other sorts of belief or committments. I have done that elsewhere.

I am happy to live in a country that is fairly secularised in the political sense. This secularisation is of the sensibly liberal and tolerant kind, where people of openly displayed, institutionalised religious affiliation are as welcome as anybody else to run for political office, and anyone that may feel like it has the right to make religiously grounded arguments to support or reject political suggestions. Of course, it is also free for all to publicly display whatever symbol of one's faith on one's body that one may please – just as free as it is for anybody to display any sort of symbol of any kind, as long as these are not of particular types of political meaning (due to hate speech considerations). At the same time, while there are quite a few people in Sweden that belong to or identify with institutionalised religious organisations, rather few take the specific content of their faith into the realm of politics or public debate, albeit this content may inspire their political opinions and influence, e.g., voting behavior. These people expect, quite reasonably so, to be left free by society and other people to practice their religion as they please within then the same legal framework that demarcates acceptable behavior for any sort of personal or life-style activity. True, other people may have opinions about this and are free to express those, just as they may have opinions on any sort of activity of other people, but that's nothing special for institutionalised religion. In cases like this, which are the most common in my own country, people's religion are undoubtedly a purely personal matter, just as one choice of favourite sports team is.

Fine. But what about when a person of such religious commitment takes it with him or her into a political career, in particular when such a person belongs to a religious institution that openly propagate particular and strong political views, say, with regard to the legislation around abortion or people of LGBTQ sexuality. This is a heated issue at the moment in my country, as our prime minister, who represents a party (Moderaterna) presenting itself mainly as a liberal or even (when it comes to taxes, public services and trade) libertarian political body – although in the now rather distant past, it used to stand for a more traditional value conservative stance (King and Country and Church and the glorious days of old and so on) – choose to include in his newly formed cabinet a minister of just this sort of religious affiliation, Elisabeth Svantesson. The choice sparked immediate controversy (here, here), as Svantesson used to belong to an extreme neo-calvinist, Christian right, militant pro-life church, called Livets Ord, has been markedly active in the organised movement against current Swedish abortion legislation,  and now belongs to a church called Kristet Centrum, that is not only openly oppose that legislation, but also openly stands for very negative views of LGBTQ people and seems to propagate a rather restrictive room for them to entertain the same rights in the area of family as others (Swedish links: here, here, here, here, here). A young, female representative of Moderaterna has publicly demanded that Svantesson officially distance herself from the political movements against legal abortion etc., or at least clarify where she stands. Svantesson herself has tried to rebut such requests as being about a "private matter", and she has been defended against the criticism by a number of debaters claiming that the critique is an example of persecution – the word "witch-hunt" has even been used – due to her religious faith, albeit one analyst has made the point that she is probably being let off the critical hook more easily than if she had been a muslim and had had a history of fundamentalist views coming from that particular camp.

My own view is the following. When a religious organisation propagates particular political views as part of its religious message, the question of whether or not a person of political office belongs to or sympathises with that institution or its message is certainly not a private or personal matter anymore. This is so, because such a religious institution is just as much a political organisation – the one does simply not exclude the other. The fact that such a political organisation also has a religious side to it cannot and should not immunise it against public critical scrutiny of the political views it represents, and the same goes for its political representatives. In this case, Elisabeth Svantesson.

The remaining issue is, of course, how sound the criticism is. With the extremely solid public support of the Swedish liberal abortion legislation (a pregnant woman a a positive right to have an abortion performed up to pregnancy week 18, after that it is very very difficult to have one and special permission is needed, but out of the question if the fetus is viable), the possible smuggling into the highest circles of political power a person committed to the opposite view would seem pretty relevant for voters. Similarly, a predominantly liberal/libertarian party lika Moderaterna, would seem to have a qualified identity problem if one of its highest political officers and most influential members represent ideas in the area of sexual orientation and identity related rights that sparks such a stark contrast to the party mainstream as reports suggest. True, with about a year to the next parliamentary elections, this is mostly a tactical problem for Moderaterna, but my point is simply that the fact that the problem has its roots in a minister's religious fundamentalist convictions does nothing to make it go away, in fact or even ideally. In conclusion, Svantesson needs to come clean and cannot hide behind a shield of alleged privacy or immunity against criticism for religion-based political ideas.

My Response to Priscilla Coleman's Article on Abortion and Mental Health Now Online at the British Journal of Psychiatry

Yep, finally, my response to Priscilla Coleman's meta-analysis that claims there to be a causal link between having an abortion and suffering subsequent mental health problems is online at the British Journal of Psychiatry website. The response targets not only Coleman, but also a number of other contributors, who have all made simplistic claims about what practical conclusions to draw from Coleman's study.

I didn't make the selection of responses that are featured in the printed issue 1 of BjP for 2012, but then again I didn't expect to, since my contribution does not address the scientific quality of of Coleman's meta-analysis.

My earlier posts on Coleman's article and the debate it has inspired can be found here, here, here, here, here and here.

Priscilla Coleman Responds to Critics

Today, Priscilla Coleman, the author of the article in the British Journal of Psychiatry presenting a meta-analysis purporting to demonstrate a causal relationship between abortion and mental health problems published a rapid reply, where she responds to her critics so far. Most of the response addresses scientific details (however, she seems to be responding only to a minor part of the scientific criticism), but a rather substantial part tries to address the claim from critics of personal bias and undisclosed conflicts of interests based on that on Coleman's part. As I understand it, Coleman's defense is that since, in her view, the American Psychological Association is furthering a pro choice stance, it is OK for her to be consciously biased in her research without telling so when publishing an article in a journal requiring disclosure of conflicts of interest. She also, seemingly without any sort of proof, accuses her critics and/or other (unnamed) researchers of sitting on unpublished studies that would support Coleman's claim. Rather remarkable, isn't it?

Read Coleman's response here.
Read my former posts on this topic here, here, here, here and here.

Stay tuned!

The Scare Tactics underlying Claims about Abortion Causing Mental Health Problems

I'm still waiting for my "rapid resonse" to Priscilla Coleman's article claiming abortion to cause mental health problems to appear at the British Journal of Psychiatry website. For my earlier posts on this matter, see here, here, here and here.

In the meantime I may point interested readers to a post by James C. Coyne (clinical health psychologist and Professor in the Department of Psychiatry, University of Pennsylvania and Professor of Health Psychology, University of Groningen), who runs a blog attached to the Psychology Today magazine. Coyne exposes the underlying political agenda of Coleman and her associates and makes the claim that, combined with the many faults of her article, this makes a case for there being an undisclosed conflict of interest. Further reason for suspecting such conflicts instead attach to BJP itself, since one of its associate editors is a loudly outspoken pro life activist known for letting ideological or political conviction dictate research findings.

Stay tuned!

Rapid Response to Coleman's Article in BJP Forthcoming

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So, following my former posts on this subject (here, here and here), I decided to enter the discussion following Priscilla Coleman's article on abortion and mental health in the British Journal of Psychiatry. My response, entitled "The Correct Use of Ethics and Precaution with Regard to Abortion and Mental Health" concerns not the scientific quality of Coleman's work or the plausibility of her conclusion, but rather the practical implications of this field of research. This is a topic cautiously touched on by Coleman herself and, much less cautiously, addressed by several commentators in the ensuing debate. I basically argue that all of the claims made to this effect are unwarranted and based on faulty reasoning. Since the letter is in submission I will not expose it here until it is either published or rejected.

Interested readers may in the meantime find great pleasure in reading the most recent rapid response from Ben Goldacre and William Lee.

Stay tuned!

More Massive Criticism of Article Claiming Abortion to Cause Mental Health Problems

The article by Priscilla Coleman purporting to demonstrate a causal link between abortion and mental health problems has been the subject of posts on this blog two times already: here and here. In summary: Coleman's attempt at meta-analysis seems to suffer from all the flaws one may imagine and it is a mystery how the peer review of the British Journal of Psychiatry can have let it pass, lest the integrity of the referee and editorial procedures of this journal is put into question.

The other day, six further so-called rapid responses to Coleman's article appeared on the BJP site. Of these, all but one expand and further develops the criticism. One response (Koch et al) tries to make the point that the recommendation to inform abortion seeking women about a risk that an abortion may endanger their mental health may still hold, even if the scientific criticism is sound. This is the exact claim that I questioned in my first posting even assuming that Coleman were to be right in her conclusion (which now seems highly unlikely). Let me quote:

...suppose that Coleman indeed is right in the strongest sense, is the most obvious conclusion then that we should move to restrict access to legal abortion? Actually not, since there is strong scientific support for the claim that such actions lead to no good (in particular, they do not prevent abortions). How about informing about the risk then? Well this looks more sensible, although, if the underlying explanation of abortion being a risk factor is that a certain portion of abortion seeking women are already burdened by mental health problems that threaten to become more serious if they are exposed to trauma of some kind, one may doubt the efficacy of such actions.

Instead, the practical conclusion that would seem to be gaining the most support would be this: Researchers like Coleman should rapidly proceed to develop instruments to identify those at risk, and abortion services should offer these women special post-abortion care and counseling, or even preventive actions before the procedure is undertaken that may serve to decrease the risk. If such an instrument proves difficult to develop, such care and counseling should become a standard ingredient of good clinical abortion practice all across the board. I must say that I find it a bit odd and worrying that Coleman's own practical suggestion does not focus on this. After all, if women's mental health is what you care about, practical implications should focus on actions directed at promoting that aim.

Koch and colleagues (one of which has a bioethics affiliation) try to make their point using the precautionary principle, and since this is the subject of a recent book of mine (likewise a forthcoming article in the forthcoming International Encyclopedia of Ethics) you may imagine that I'm tempted to enter the rapidly growing rapid response community myself. For that reason, I will wait a bit commenting on that particular thing until I decide whether or not to address to BJP what is, in several elementary senses, either severe misuse of the notion of this principle or the use of an obviously implausible version of it.

Call for Retraction of Article Claiming Abortion to Cause Mental Health Problems

The controversy grows regarding an article published in the British Journal of Psychiatry some weeks back by Priscilla K. Coleman, presenting a meta-analysis that purports to demonstrate that having an abortion is a causal factor for subsequent mental health problems. It is important to understand that this claim is not only about there being a statistical correlation between having an abortion and suffering from subsequent mental health problems. The presence of such a correlation is well-established in research around abortion since a long time, and is not doubted by anyone. However, many closer analyses have revealed that the correlation is not due to the having of an abortion giving rise to mental ill-health. This since, among other things, there is an over-representation of mental health problems among abortion seeking women. Indeed, in a recent very ambitious study, published in the very prestigious journal New England Journal of Medicine, it is shown that probably mental health problems is a causal factor of establishing of an unwanted pregnancy. So, in fact, it would seem that the causal link goes the opposite way of what Coleman is claiming. I raised these concern already in my first posting on this subject.

Now, the distinction between a statistical correlation and a causal link is elementary to scientific inquiry - it is, one might say, to research as knowing the alphabet is to writing. In my original posting, I therefore assumed that Coleman had probably controlled for the presence of pre-pregnancy mental health problems, as well as other possible explanatory factors (so-called confounders) in her analysis – reserving my critical comments mainly to biased news reporting of her results. However, subsequent harsh criticism from leading researchers in the field, reported about in another posting, revealed that not only had Coleman not done this elementary footwork, she had made a grossly biased selection of the studies underlying the analysis (with about half of these being of her own or her group and many top-quality studies excluded), included many studies that use deficient methodology (not least those of her own), and – as if that was not enough – undertaken her meta-analysis ignoring several standard ingredients employed and agreed to by researchers world-wide in order to avoid common mistakes and biases. Based on that, I voiced concern about the integrity and quality of the BJP peer review process and editorial policy and speculated about a call for retraction of Coleman's paper (which, in the scientific world means that the content of the article is no longer considered to be valid science). The sub-standard scientific quality pointed out by the critics is reason enough, but since Coleman's conjecture (for this seems what it is) was immediately taken up by anti-abortion extremists world-wide, the editor needs to consider the obvious harm that continued support of the article can have – a harm, due to the scientific flaws of Coleman's work, that is effected for no good reason.

After that, two more critical (so-called "rapid") responses to Coleman's article have been published in BJP. One of these (by David Ferguson,  John Horwood and Joseph Boden) attempts to defend Coleman, mainly by attacking one of the critics. However, the very serious criticism voiced in the other responses is simply ignored. Moreover, it is obvious that Ferguson et.al. seem to be as oblivious to the elementary distinction between statistical correlation and causal linkage as is Coleman. They write:

....despite the claims made in previous reviews about the absence of association between abortion and mental health, when data are pooled across studies there is consistent evidence suggesting that women having abortions are at modestly increased risks of mental health problems when compared with women coming to term with unplanned/unwanted pregnancies.

Note here that the expressions are "association between abortion and mental health" and "increased risk". Does this support Coleman's conjecture about a causal link? No, it does not, as everyone who has ever taken a primer in statistical method knows. In fact, "association" and "increased risk" means the same, and this meaning is that there is a statistical correlation between having an abortion and suffering from subsequent mental health problems that is stronger than that between carrying a pregnancy to term and suffering from subsequent mental health problems. Yes, you read rightly, the same statistical correlation that is generally agreed on by everyone. Ferguson et.al. either seems to have mistaken what the issue worthy of inquiry is from the outset, or missed some crucial lessons of science class. In short, this response is a misnomer and completely irrelevant to the debate on Coleman's conjectured findings.

So, the basis for assessing Coleman's article as ripe for retraction seems to stand. Not surprisingly then that just such a call was today sent to BJP. I happened to come to know about it through one of the internet forums of my own field of research (the Bioethics International group on Facebook), asked the author of the call to see it, and received his permission to quote it verbatim. It will still take a few days for BJP to decide whether or not to publish it among the "rapid responses", but until then (or in case the editor should chose to try to avoid the embarrassment of publishing it), you can read it here in its entirety:

Coleman Article Should be Retracted, Not Debated in a Subsequent Issue of BJP

Serious flaws in the reporting and conduct of the Coleman review should have been identified in pre-publication review and not left for readers of BJP to sort through subsequently. The article should be retracted and should not given the dignity of post-publication debate in a subsequent issue of the journal.

The review lacks the fundamental transparency that is expected of systematic reviews and meta-analyses and needed to allow readers to independently evaluate its conduct and interpretation of results without having first to go back to the original studies. Search strategies are not even provided in sufficient detail for readers to ascertain the adequacy and completeness of the retrieval of relevant studies.

Results for 36 effects obtained from 22 studies that are integrated into a single effect size represent highly diverse outcomes ranging from smoking of marijuana to suicide. The overall effect size that is calculated does not generalize back to the individual outcomes in any meaningful way. This aspect of the meta-analysis recalls a photo often incorporated into workshops on meta-analysis. The photo depicts the famous road sign for New Cuyama, California in which a total of 4663 is indicated for a population of 562, an elevation of 2150 feet, and a date of establishment of 1951.  The calculation of an estimate of the heterogeneity of the effect size reported by Coleman is missing, in violation of standards for reporting a meta-analysis.

Multiple effects sizes are obtained from individual studies are integrated in a way that violates basic assumptions of independence of individual effect sizes that are required for a meaningful meta analysis. The 22 studies include 13 from Coleman's author group, and so the meta analysis violates usual expectations that a meta analysis be independent of the author group who generated the original studies. David Reardon who is a co-author of Coleman on a number of these studies has declared his strategy [1]:

"For the purpose of passing restrictive laws to protect women from unwanted and/or dangerous abortions, it does not matter if people have a pro-life view...In some cases, it is not even necessary to convince people of abortion's dangers. It is sufficient to simply raise enough doubts about abortion that they will refuse to actively oppose the proposed anti-
abortion initiative. In other words, if we can convince many of those who do not see abortion to be a 'serious moral evil' that they should support anti-abortion policies that protect women and reduce abortion rates, that is a sufficiently good end to justify NRS efforts. Converting these people to a pro-life view, where they respect life rather than simply fear abortion, is a second step. The latter is another good goal, but it is not
necessary to the accomplishment of other good goals, such as the passage of laws that protect women from dangerous abortions and thereby dramatically reduce abortion rates."

Many of the studies included in the Coleman meta-analysis, including most of the studies conducted by her group, are strongly criticized by other researchers and excluded from consideration in other systematic reviews, including a forthcoming report by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists
(RCPsych). One can only speculate on the timing of the BJP's publishing of Coleman's review relative to the impending release of the RCPsych report. Results of some of the original Coleman studies are not replicated in subsequent re-analyses of the same data sets by others. Coleman integrates results from studies without controlling for measures of mental health outcomes obtained prior to an abortion and in a number of instances, the mental health outcomes entered into her meta analysis were obtained before the abortion. In other instances, the effects reflect differences between women who obtained an abortion for an unwanted pregnancy versus women who delivered a wanted baby, a grossly
inappropriate comparison if the intention is to obtain a valid estimate of the effects of abortion on mental health.

It is a mater of  technical details, but important to evaluating Coleman's meta analysis that she used the wrong formula to calculate population-attributable risk and violated basic assumptions for such a calculation.

These serious flaws were apparent in a cursory reading of Coleman's article. I am confident that a closer read and a retrieval of the original studies and others that were ignored by Coleman would have yielded still more problems. But I think this analysis reaches the threshold for demonstrating the necessity of retracting the Coleman article and it begs an explanation for the nature of the peer review that led to the article being accepted.

The Coleman article is not a contribution to scientific literature but rather represents the revenge of Coleman and her offer group on the scientific community which has held their work to basic objective scientific standards, criticized its poor quality, and excluded from
integration into systematic reviews on the basis of objective criteria.

1. Reardon DC (2002). A defense of the neglected rhetorical strategy (NRS). Ethics Med 18 (2): 23-32.

James C. Coyne, Ph.D.
Director, Behavioral Oncology Program
Abramson Cancer Center and
Professor of Psychology
Department of Psychiatry
University of Pennsylvania School of Medicine
http://bit.ly/Coyne_ISI
http://www.afcri.upenn.edu/ourfaculty/coyne_bio.html

Careful as I am, not being an expert in this field, I still must say that the combination of the massive sound criticism against Coleman's analysis and methodology, as well as the obvious fault that I can spot myself, should have the editor make the retraction move. The obvious ideological agenda underlying the research of Coleman and her team, pointed out also in another of the rapid responses, adds to this, since it makes probable the hypothesis that the faults of Coleman are not (only) the result of incompetence, they are deliberately engineered to achieve the shallow appearance of publicisable scientific claims in order to give the political anti-abortion movement its 15 minutes fame.

Claim About Abortion Causing Mental Health Problems Falling Apart

The suggestion in an article in the British Journal of Psychiatry by researcher Priscilla K. Coleman that abortion causes mental health problems now seems to be rapidly falling apart. I voiced some doubts about the quality of Coleman's meta-analysis when posting about her article a while back, and it now seems that exactly the sort of basic faults that I worried about are present in Coleman's analysis. But it doesn't stop there. Two responses to Coleman's paper, both published in the BJoP, point out a number of rather grave deficiencies, and one may seriously wonder when the journal editor will start to think retraction. One may also wonder about the integrity and quality of the peer review process leading up to the publication of Coleman's article. Here are a few snippets of what the critics say:

Huge numbers of papers by respectable researchers that have not found negative mental health consequences are ignored without comment. Not surprisingly, over 50% of the "acceptable" studies she uses as her "evidence" are those done by her and her colleagues Cougle and Reardon. The work of this group has been soundly critiqued not just by us (1, 2) but by many others as being logically inconsistent and substantially inflated by faulty methodologies. As noted by the Royal Society of Obstetricians and Gynaecologists (3), the authors consistently fail to differentiate between an association and a causal relationship and repeatedly fail to control for pre-existing mental health problems. We note that she did not include in her articles the publication by Munk-Olsen et al. in the Jan. 2011 New England Journal of Medicine (4) that concluded that "the rates of a first-time psychiatric contact before and after a first-trimester induced abortion are similar. This finding does not support the hypothesis that there is an overall increased risk of mental disorders after first-trimester induced abortion". (Gail Erlick Robinson MD, DPsych, FRCP Professor of Psychiatry and Obstetrics/Gynaecology University of Toronto
Nada L. Stotland MD, MPH Professor of Psychiatry and Obstetrics/ Gynaecology Rush Medical College
Carol C. Nadelson MD Professor of Psychiatry Harvard Medical School)

This quantitative synthesis and meta-analysis did not follow the robust methodologies now generally accepted for systematic reviews[1]. There is no detail of the search strategy including search terms; the strategy is not comprehensive (only two databases included); other strategies to search the literature including citation tracking, hand searching and contacting authors and experts in the field to try to minimise publication bias were not carried out; and there was no assessment or rating of the quality of included studies, so that only those of at least reasonable quality are included in the meta-analysis. This is particularly important here as many of the primary studies included in this review have significant methodological limitations, including non-prospective design, non-standardised measures of mental disorders, lack of adjustment for pre-existing mental illness, lack of adjustment for other key confounders (e.g. social deprivation), non-comparability of exposed and non-exposed groups, and selection bias. [...]

Finally, the synthesis of the data and the summary statistics are flawed. The criteria for synthesizing data meant that several effect measures were included from the same study. Eleven of the included studies contributed more than one effect measure, with two studies contributing four measures each. Despite the clustering of effect measures by study, they are analysed as independent measures. This is an important limitation, since the use of several effect measures from a flawed study can magnify the bias. 

Most importantly for readers of this study to know, is the erroneous conclusions drawn by the author regarding the Population Attributable Risk (PAR). The underlying assumptions for estimating PAR include that there is a causal relationship between the risk factor (abortion) and the disease (mental health) and that there is independence of the considered risk factor from other factors that influence disease risk[8]. These assumptions are clearly not met in this review and therefore it is completely inappropriate to calculate a PAR from these data.  (Louise M Howard*, Hind Khalifeh*, Melissa Rowe*, Kylee Trevillion*, Trine Munk-Olsen†,
* Section of Women’s Mental Health, PO31, Institute of Psychiatry, King’s College London †National Center for Register-Based Research, Aarhus University, Aarhus, Denmark)

The first of these critics also point out:

 Reardon, the leader of this group, has clearly expressed his new rhetorical strategy as "we can convince many of those who do not see abortion to be a "serious moral evil" that they should support anti-abortion policies that protect women and reduce abortion rates" (5) . He has stated that "I do argue that because abortion is evil, we can expect, and can even know, that it will harm those who participate in it. Nothing good comes from evil." (6). These authors have a clear agenda and publish a steady stream of papers, based on faulty methodology, designed to prove their point. If we and other researchers know this, how is it that reviewers for esteemed journals such as yours consistently fail to recognize these deficiencies and biases?

In short: Coleman and her group has an established track record of faulty, sub-standard and biased research. The article in question has applied faulty methodology on several counts, some of which is so obvious that even a happy amateur like myself could spot it. So, dear editor of BJoP, how come that this article could sneak through the peer review process? How was peer reviewers selected, for example?

Abortion, Mental Health Problems and the Politicisation of Science

Just the other day, several UK newspapers (here, here) reported about a new, ambitious study on the relationship between abortion and mental health problems. Undertaken by Priscilla Coleman, professor at the Bowling Green State University, and published in the well-renowned journal, British Journal of Psychiatry, the study is a so-called meta-analysis where data and results from many different studies in this area are brought together and analysed as a whole. The result is that evidence speaks in favor of a significant statistical correlation between abortion and elevated risks of mental health problems after abortion. Not surprisingly, this news have been ceased on by political campaigners who want to push for more restrictive abortion legislation. Coleman herself is markedly more modest, concluding only that...

Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

In the news reporting, this statement has generally been read as a call for telling abortion seeking women about the risks. Now, if you believe in individual liberty, women's right to decide over their own body or is generally oriented towards pro-choice positions on abortion, this may not appear to be very shocking. After all, abortion is a serious medical or (when undertaken in later stages of pregnancy) surgical procedure that is often undertaken in the context of a personal crisis. If there indeed is a link between undergoing this procedure and suffering mental health problems, this should be explained to women contemplating abortion, shouldn't it? However, there are several question marks surrounding Coleman's result and what conclusions can be inferred from it, both scientifically and with regard to policy.

First, neither the news reporting, nor the abstract to the actual article reveals if and to what extent Coleman's analysis has controlled for relevant so-called confounders – i.e. other factors contributing to the onset of mental health problems. In particular, it is unclear to what extent the analysis has factored in the presence of mental health problems or risk factors for such problems before abortion and, indeed, pregnancy. When I had reason, several years back, to look at research in this area undertaken in Sweden, a repeated phenomenon was that there indeed were correlations between abortion and mental health problems, but that the occurrence of this problems almost always could be linked to the presence of such problems (or risk factors for them) before abortion or even the actual pregnancy. Now, Coleman's results indeed indicate that women who undergo abortion have elevated risks compared to a substantial control group. However, in lack of controlling for the presence of problems before abortion, this may just as well support the notion that women already suffering from mental health problems or who are victims of risk factors for this are more likely to establish pregnancies that they eventually would prefer to have terminated. Indeed, such a link was suggested by a large Danish study published last year in the highly ranked journal New England Journal of Medicine. This, in turn, may depend on a lot of different things, such as being placed in a dysfunctional psycho-social context (e.g. lack of a reliable partner, poverty, disorganised housing situation, et cetera). Hopefully, time will tell what quality Coleman's study actually possess in this respect and, in the case of deficiencies, that further studies are undertaken to investigate the issue.

However, even if it turns out that Coleman's results hold up to closer scrutiny, the sort of factors just mentioned make the interpretation of Coleman's practical recommendation made in the media quite odd, if not biased – just as the one reported about the reaction of many campaigners against liberal abortion legislation. For suppose that Coleman indeed is right in the strongest sense, is the most obvious conclusion then that we should move to restrict access to legal abortion? Actually not, since there is strong scientific support for the claim that such actions lead to no good (in particular, they do not prevent abortions). How about informing about the risk then? Well this looks more sensible, although, if the underlying explanation of abortion being a risk factor is that a certain portion of abortion seeking women are already burdened by mental health problems that threaten to become more serious if they are exposed to trauma of some kind, one may doubt the efficacy of such actions.

Instead, the practical conclusion that would seem to be gaining the most support would be this: Researchers like Coleman should rapidly proceed to develop instruments to identify those at risk, and abortion services should offer these women special post-abortion care and counseling, or even preventive actions before the procedure is undertaken that may serve to decrease the risk. If such an instrument proves difficult to develop, such care and counseling should become a standard ingredient of good clinical abortion practice all across the board. I must say that I find it a bit odd and worrying that Coleman's own practical suggestion does not focus on this. After all, if women's mental health is what you care about, practical implications should focus on actions directed at promoting that aim.

Presumed Guilty Until Proven Innocent - Legal Security Out the Window in New Utah Law that Criminalises Miscarriage

Yes, indeed you read correctly! The US state of Utah has adopted a bill according to which women who suffer miscarriage are to be assumed guilty of murder, unless proven innocent. In reports from inside and outside the US, the flabbergasted reactions have taken up the themes of the so-called Pro Life movement now showing its true face ("so now we see, they're after women after all"), and the problematic or at least uncertain implications in relation to the classic Supreme Court ruling of Roe vs. Wade from 1974, that paved the way for legal abortion in the Unites States. But, in my view, the problematic aspects of this case go way deeper than that, and has little to do with the moral or legal status of abortion. This bill assaults basic principles of legal security that are a necessity for any country that wants to label itself minimally civilized, whatever regulation of abortion, pregnancy, etcetera, one then might want to adopt.

The bill originated in a case where a 17 year old pregnant woman that had passed the time limit for legal abortion allegedly hired some guy to assault her physically in the hope of thereby inducing a miscarriage. This did not happen, so the guy was convicted for something else than murder, presumably some form of attempt. The woman (technically rather a girl at the time of the event), however, turned out not to be possible to convict for anything. Horror!!! Hence the new bill.

I wonder if it is only us non-Utahits that find this reaction particularly twisted? First, the desperation of the 17-year old girl clearly says something quite salient of the situation that the authorities of Utah leave underage, involuntary pregnant females in. Perhaps doing something about that, huh?! But I presume that the morality underlying the bill would prevent anything in that vein - "Helping a slut? What's the matter with you?!", is the expected reaction. Another case of what becomes of the message of love when unattended to by secular reason - something I have commented on before. Second, an online-acquaintance's spontaneous reaction - as my mother's - to the news about the bill was a hands on analogy with the Taliban rule of Afghanistan, and this strikes me as dead right. This perverse obsession with punishment rather than prevention out of compassion is as clear a sign as anything of the supporters of the Utah bill sharing with the Talibans the same brutal idea of how to react to the plight of others. But this is not my main point.

Neither is my point about this case being another in a quite disturbing trend in developed nations to use the pregnancy as an excuse to treat women as instruments for one thing only: the population of the earth. This recent incident from Florida may remind readers about what I'm talking about. In my work in health care ethics, I have noticed a clear rise in enthusiasm among medical staff regarding the possibility of submitting pregnant women to treatments against their will for the sake of the fetus. Conclusion: women, when pregnant, are to be treated as means only and the worry about where to draw the line is of minor consequence. But let's do what philosophers often do: let us lend the supporters of such ideas the benefit of the doubt. Let's assume for the sake of argument, as the saying goes, that actions of women that endanger fetuses are indeed to be viewed as a potentially criminal offense.

On this assumption, my point is this: the Utah bill prescribes society to apply a principle of presuming all pregnant women undertaking any sort of action that may pose some danger to the health and well-being of the fetus they are carrying as guilty of an offense. It is not society that carries the burden of proof of demonstrating the actual occurrence of this offense, it is the accused. First of all, unless some rather vast changes (that will never pass even the first round of an appellate court and even less the supreme court) in the Utah criminal code are undertaken this implies that men and women are judged according to different basic legal principles. If that does not violate the US constitution, I wonder what does! But this is not all. The whole idea of presuming people guilty of crimes, in particular crimes that may be followed by harsh punishment, violates the most basic principle of a fair, just and sustainable legal system that is to be found. For, comically as it would be had it not been for the brutal stupidity of it all, as people like Stalin have proven beyond reasonable doubt, the only consistent application of this principle is the incarceration of the entire population. For, of course, men will have to be judged by the same standard, and as we know, one of the main threats to the health and well-being of women is the actions of men.

And here's the real irony of it all: the bill seems to imply that the entire population of political representatives that voted in favor of the bill, as the public servants that will be enforcing it, have to be prosecuted for exactly the crime described by the very same bill! One needs just a minimum of empathy and imagination to understand the effects of the Utah bill on the pregnant women of Utah. Whatever they do, they will risk having the police banging on the door, dragging them off on a presumed murder charge. For, as we know, anything a pregnant woman does may have effects (given the circumstances) that makes more probable some downside for the fetus. So, the main effect of this new policy will be the inducement of severe fear and stress on pregnant women - a factor well-documented to pose a serious health risk to both woman and fetus. So, come on you Utah law-makers, let's have it all out and see you in court!