Slides to Two Recent Talks Connecting the Themes of Ethics, Crime and Psychiatry are Now Online

Just to inform that the slides to my two talks at the 33rd International Congress of Law and Mental Health, held in Amsterdam earlier this summer, are now available online for viewing, download and sharing via my Academia.edu site. Both talks represent work in progress, where I am in the beginning of combining thinking on different topics that I have been touching on in isolation before, but which are nevertheless related through their connection to certain aspects of criminal law policy connecting to medical views of human nature.

They are:

1. The Return of Lombroso? Ethical and Philosophical Aspects of  (Visions of) Forensic Screening

Abstract
Italian nineteenth century criminologist Cesare Lombroso is notorious for his seminal ideas about criminality and anti-social behaviour resulting from physiological anomalies that should be detected by society and used for forensic preventive purposes. After an extended period of disrepute following World War II, similar ideas have been resurrected in psychiatry, genetics, neurology and criminology in the past decade or two. In particular, there is a growing focus on early detection and application of preventive measures. This development actualizes a complex web of ethics and policy issues having to do with the well-known fact that screening and prevention in the health area are far from ethically clear-cut activities and actualize vivid prospects of doing extensive harm to individuals as well as society. Also, taken to its extreme, it actualizes the idea of using prenatal or preimplantation testing to preselect against children with a predisposition for criminal or antisocial behaviour. In the forensic case, such screening-prevention strategies will connect further to a complicated issue about the proper use of risk-assessment models for societal decision-making for precautionary purposes. Based on former work in all of these areas, this presentation will outline and analyze the basic issue of the defensibility of activities of this sort, with the perspective of forestalling unintentional harm to individuals and society.

And.....

2. Hate Crime, Mental Disorder and Criminal Responsibility

Abstract
Hate crimes are ordinary crimes committed in connection with a negatively prejudiced, biased, disparaging, or antagonistic attitude towards the victim in terms of a perceived membership of a social group. Some hate crimes are elaborate political acts of terror or elaborate persecution, some are so-called “hate speech”, but the overwhelming majority are instances of mundane criminality, involving everything from murder to theft and harassment. Hate crime policies rest on the idea that the bias or “hate”feature make such crimes worse, and that offenders for this reason should be held more firmly responsible. At the same time, the attitude of making a crime into a hate crime involves more or less distorted ideas about reality, together with a willingness to transgress social norms on that basis. In some cases, these views amount to major delusions, resistant to rational scrutiny. In other cases, we may move closer to a point where the belief-desire cluster can be seen as ordinary negligence. Thus, many hate crimes have features that may be argued acting to diminish responsibility according to standard ideas in the philosophy of punishment. The presentation maps underlying value conflicts, tensions, and incoherence in legal practice connected to this complexity of criminal law.

Enjoy for what it's worth!

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

"

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.