Changes to NSW abortion bill raise further questions

Matt Woodley

9/08/2019 3:59:45 PM

Proposed legislation to decriminalise termination of pregnancy has passed the New South Wales lower house, but some amendments may prove controversial.

Pro-choice protesters
Debate over the bill saw protesters from both sides of the argument come out. (Image: Dean Lewins)

In particular, the NSW branch of the Australian Medical Association (AMA) has criticised the inclusion of an amendment requiring doctors to receive ‘informed consent’ before proceeding and accused some members of parliament of ‘unfounded fearmongering’.
The AMA also decried attempts to alter the bill’s wording surrounding conscientious objection and a failed push that would have required abortions after 22 weeks to be the subject of a review by a four-person panel.
The Reproductive Health Care Reform Bill 2019 was eventually passed with seven amendments in a conscience vote following two days of extended debate, with 59 members in favour and 31 opposed.
Professor Danielle Mazza, women’s health expert and Head of General Practice at Monash University, told newsGP that while she is pleased the bill passed convincingly, she believes many of the amendments are ‘unnecessary hurdles’ for women seeking to access the procedure during a vulnerable time in their life.
In particular, she describes the informed consent amendment as ‘ridiculous’, describing it is an attempt to regulate abortion in a different way to other medical procedures.
‘Anything that adds confusion or makes termination of pregnancy different, adds to stigma and puts in place small barriers for patients,’ she said.
‘Why should this be separate from any other procedure that doctors undertake?
‘[It] does not stand in line with the intent of the legislation, which is to put this within health rather than criminal law … this area needs to be like any other area of healthcare and dealt with in the same way.’

Professor Danielle Mazza believes many of the bill’s amendments are ‘unnecessary hurdles’ for women seeking to access the procedure during a vulnerable time in their life. 

Professor Mazza also questions an amendment that would require doctors to assess whether it would be ‘beneficial’ to discuss counselling with the patient and provide options if they are interested.
‘It’s not the doctor’s decision. It’s the patient’s decision as to as to how they proceed and whether they would like to have counselling,’ she said.
‘It’s telling doctors how to do medicine, it’s unnecessary.
‘It’s another barrier, another way to make this procedure different from other health procedures and it is not helpful.’
RACGP NSW&ACT Chair Professor Charlotte Hespe also believes the amendment stipulating doctors obtain informed consent is unnecessary, but does not think it will prove to be a barrier.
‘I don’t understand why they put it in, because that’s what we do,’ she told newsGP.
‘But if it at least provided assurance to those who are against the bill and meant it went through, then it’s only ridiculous to those of us who know that’s what we do anyway.
‘With any termination of pregnancy we need to ensure that all our patients have an informed understanding of what it is that they are going to do.
‘We have modules, particularly around abortion, that train GPs to understand how to do that, because one of the big things we know is that women who have a termination on an emotive response – for example, “This is inconvenient, and I can’t deal with it” – are much more likely to have consequences down the line in terms of regret and anger.’

Professor Hespe also does not believe the notion of informed consent separates termination of pregnancy from other procedures.
‘My understanding is that there would be no patient who has a termination of pregnancy in New South Wales who doesn’t already have to sign a form of consent before they have a procedure,’ she said.
‘There is no operating theatre that allows any type of procedure without the patient signing a form. That’s good practice.
‘We need to make sure that the patient has understood that if there’s a complication they could, for example, potentially rupture the uterus or be rendered sterile as a result of it going absolutely wrong.
‘All of those considerations need to be explained to people, and they need to sign off before they have a termination.’

RACGP NSW&ACT Chair Professor Charlotte Hespe said amendments that require doctors have a certain level of expertise are appropriate.
An amendment of which Professor Hespe is supportive relates to the need for at least one of the two doctors required to approve a termination after 22 weeks to be a medical practitioner with relevant expertise, such as a GP with additional experience or qualifications in obstetrics, or a specialist gynaecologist or obstetrician.
‘If it’s after 22 weeks, I think that’s absolutely appropriate. By that stage there should have been a specialist obstetrician involved in their care anyway,’ she said.
‘There are all sorts of implications and potential complications related to termination of pregnancy in terms of bleeding, damaging the cervix, rupturing uteruses; you need to have someone who knows what they’re doing.
‘Those particular caveats are reasonable in terms of how we practice medicine, and what we would expect for the delivery of safety and quality care, particularly in the Australian setting.
‘I don’t want any doctor just undertaking this service who hasn’t got any extra expertise, but I  wouldn’t want anybody doing that for a typical termination, either.’
However, Professor Mazza disagrees.
‘I don’t see the logic in the amendment at all. There’s nothing that a specialist obstetrician or gynaecologist would necessarily do differently to any other doctor assessing this kind of situation, and again, it puts up another barrier,’ she said.
‘Women who are seeking termination after 22 weeks are doing so for specific reasons. So either it’s because of an abnormality that’s been detected through mid-term screening or in another fashion, or potentially these are women with significant health or social issues.
‘In my experience, they have been women who’ve had significant psychiatric illness or significant drug and alcohol issues. Other cases I’ve commonly seen seeking late termination have been international students who are at risk of significant repercussions if they return home pregnant and haven’t been able to navigate the system in time because of their ignorance of the system.’
The bill will be considered by a Legislative Council inquiry next week and is expected to be voted on the following week.

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Johnny Khoury   10/08/2019 7:44:03 AM

This legislation will be the only one we have that compels referral. Since when is a doctor compelled to refer for any particular condition? The crux of this legislation is to attack those doctors who understand that this is an attack on the sanctity of life. How did we go so far?

Dr Effie Parakilas   10/08/2019 10:07:35 AM

I respectfully and strongly disagree with you Professor Mazza.
Emphasising the need to consider counselling is extremely important.
A GP is often the initial contact point for a woman faced with unintended pregnancy. I think the GP who does their job well in this setting listens carefully, presents ALL available options, encourages a woman's trusted supports to be involved in her decision and follows up, whatever the woman decides.
If the woman decides to proceed with a TOP, and she's sitting in the abortion clinic, giving fully informed consent to the procedure (how the procedure is done and its risks, both physical and psychological), and the doctor notices she's uncertain, anxious, ambivalent, that doctor should call a 'time out' and indeed evaluate whether this woman needs further counselling BEFORE she proceeds, because as Dr Hespe says, the repercussions are significant. I'm sure many GP's have counselled women who have significant regret following a TOP. I certainly have.

Peter Bradley   10/08/2019 10:19:55 AM

I'm quite sure the sky won't fall on anyone's head as a result of the passing of this bill. However, sadly, as with other legislation, (eg VAD) these nit-picky amendments are only there to placate those opposed, in the hope it will help get the bill through. The consequence often being to make the service less easily available, and a more complicated, costly, and stressful process. In the case of VAD, not available at all to some who might well deserve to benefit from the service.

Anonymous   10/08/2019 11:44:04 AM

Shouldn’t reporting of controversial topics like this seek both sides of the argument?

Why has newsGP presented the case here as if all GPs are opposed to any amendments in the abortion legislation? The college has a membership across the country with GPs who hold a variety of ethical viewpoints - all sharing the common goal of seeking to provide good patient care.

Ewen Cameron   10/08/2019 9:56:04 PM

I’ve been a GP for 30 years.
I’ve recently become a grandfather.
This has been one of the greatest ,most joyful most wondrous experiences of my life.
Being born 8 weeks early meant visiting the special care nursing.
What s place of love and care from the nurses and doctors and wonder and joy and appreciation from the parents and grandparents!
It was magic!
Such a different experience from my student days when I got into trouble for not being properly gowned up and had no room in my little brain for joy and wonder but only the “clinical picture” and the facts I needed to pass the next exam.

I’m so glad Charlotte was given the chance to exist.
The open slather on abortions (often late) with the passing of the bill and the mind numbing objections of the AMA to amendments and the comments of Prof Mazza are horrific and offensive.

Ian Denness   10/08/2019 10:30:05 PM

As usual, RACGP presents its viewpoint as being totally one-eyed. Among GPs there is a much wider community of caring and thinking doctors than just those who have become part of the complicated 'death culture' of abortion and euthanasia.
Whilst sitting in the gallery listening to the debate mentioned above in the NSW parliament on my day off this week, I was amazed that those impassioned MPs, striving to push the bill through as quickly as possible, only spoke of one 'victim' in regard to abortion, the woman, who truly has a problem with an unplanned pregnancy.
However, the preborn baby, the one to be killed, the even greater victim, was not mentioned at all. It is as if we have gone back to a time when ultrasounds showing the complexity and beauty of the maturing baby are not available. Possibly, back then, the product of conception could be called just a 'collection of cells' or 'some tissue'. But not now, if we have eyes to see this unique person, also our patient.

Dr Lucy Van Baalen   10/08/2019 10:41:44 PM

Well said, Dr Effie P. Unfortunately, unlike other "procedures", women with a crisis pregnancy aren't properly informed of their options, risks or consequences, and counselling is not adequately encouraged. Abortion should be viewed as a last resort for women in a difficult situation - women are often under a great deal of stress at the time, so how can it be a good thing to rush a complex emotional decision without given them space and time to think? There should actually be a full checklist covered in the informed consent, including giving women the 3 choices of 1) keeping the baby and supports available 2) adopting the baby and the process 3) abortion - what that involves with the stage of the pregnancy, especially the 2nd stage abortions, and whether this sits comfortably with their own beliefs and whether they would grieve the decision if they could never have children.

Ewen Cameron   11/08/2019 6:17:28 AM

Re “Our bodies Our rights”
Once doctors were expected to be wise. This implies an understanding that rises about our cultural moment and “ the facts”.
I quote.
“Medicine has vastly improved our lives but we have lost the definition of life itself.
For the men of old the cardinal problem had been how to conform the soul to reality and the solution had been knowledge, self discipline and virtue. For the applied sciences the problem is how to subdue reality to the wishes of men( and women).
Some change isn’t it?
If living is at the mercy of the moment then dying is as much an option as living. “

Deirdre Little   12/08/2019 10:18:39 PM

I have been disappointed by the silence or perhaps ignorance of RACGP concerning fetal pain. This Bill makes no provision for relieving fetal procedural pain. Fetology has demonstrated the ability of the unborn child to feel pain. Surgeons who operate on the fetus now sedate the unborn child to prevent fetal movement in response to painful procedures. Because the unborn are unable to tell us what they are feeling, researchers rely on observation of the physiological and biochemical signs of pain to assess its presence. Evidence for pain of the unborn must be based on behaviour, anatomy and physiology.
In 1994, those performing procedures on the fetus observed that he or she reacted strongly to needle sampling from the vein in the liver, and began breathing rapidly. This fetal response was not observed when blood was collected from the placental vessels . Their data suggested that the fetus mounts a hormonal stress response to invasive procedures.

Elias samaha   13/08/2019 1:41:22 PM

The proposed bill is scientifically and ethically flawed and I am ashamed to be a part of a college that has no regard for the life of the foetus.

Bill is scientifically flawed because it argues that the person making the decision is the mother who’s body it is , and argues individual autonomy to health. I wish to pint out infants body is separate to the mother it has a different and unique genetic makeup. Mother makes the decision to terminate and the foetus does the dying . So where the rights and autonomy of the foetus?

Because the foetus can’t complain , or vote or make a complaint to ahpra , or has any voice, the foetus has to endure the pain of dying when the foetus has done nothing wrong. The bill seems to be more concerned of protecting the lifestyle of people who make irresponsible decisions and wish to take no responsibility for such actions .

The problem is mainly to do with the self centered society we now live in guised under human rights and health autonomy

Peter Coleman   17/08/2019 7:57:19 AM

Killing is never a solution
Professor Mazza, your assumption or goal that killing a baby is a normal medical condition is flawed at the least but horrific if we sit down to think about it. Our society provides pregnancy care at a high level, how privileged are we?, and I encourage the federal and state government to increase funding to this area. Adoption , caring for the disabled are caring and ‘ normal medical procedutes’ , professor Mazza. Killing a baby is murder. Doctors don’t do it.
Yours faithfully,
Peter Coleman

Jean Atalla   17/08/2019 8:09:14 AM

In this age of human rights who is going to stand up for the right of the unborn human foetus to live if we as a medical profession fail to do so.
Termination of pregnancy is not like any other medical procedure it is ending the life of an unborn baby. Not an action to be undertaken lightly.
Medical science now has the ability to save the life of preterm infants yet that same science is ending the life of so many.
I entered the medical profession to preserve life & do no harm to the patient not to destroy life. This bill is challenging the very sanctity of life itself.