Inconsistencies in therapeutic abortion report To the editor: I read with interest the article entitled "Assessment of the structure and function of the therapeutic abortion committee" by Dr. M.E. Krass (Can Med Assoc J 116: 876, 1977). There are a few inconsistencies in his report, as well as fallacies that have crept into the discussion of this problem and have been accepted as gospel. Dr. Krass has attempted to point out the problems of the function of a therapeutic abortion committee and has concluded that they are related to the ambiguity of the law as it is presently written. One of his comments is that there is no provision for appeal in the present law. I am constantly surprised that people who obviously wish to see the law done away with and believe that the law has no place in medical affairs of this nature are quick to use legal aspects when the discussion suits them. If an abortion request is a medical problem, the patient is perfectly at liberty to seek counsel from some other physician or, indeed, some other hospital committee. So, in fact, one can appeal with the present law. Dr. Krass seems to imply that it is wrong to leave "the question of the termination of pregnancy entirely to the wisdom of the therapeutic abortion committee as this committee interprets the law and the situation of the individual applicant". I think there are many precedents in law. The interpretation of the statute is dependent upon the court, judge or jury involved with the first case. So I see nothing unusual about a therapeutic abortion committee in one hospital interpreting the law slightly differently from another. It seems the Badgley committee was set up to look into another problem Dr. Krass raises; that is, the regional inconsistency in the application of the law. I fail to understand why this inconsistency has been a surprise. Does Dr. Krass think for one moment that the application of health care in other areas, such as hysterectomies, sterilizations or cholecystectomies, is consistent across the country and in various areas of the same province? Does not the patient in a rural village often have to travel to a major centre to have major surgery carried out, even when it is an emergency, let alone when it is an elective situation? Does he really believe that every small hospital in the country should have a therapeutic abortion committee or indeed be competent and allowed to do therapeutic abortions? If he believes that should be the case, then he should be consistent and apply the same reasoning to all other medical problems.

I am also puzzled by his series of discussions concerning the potential biases and subjectivity of the therapeutic abortion committee members. Are they more biased and more subjective or more religious? Do they hold more philosophical beliefs than the practising physician, their colleague, who initially saw the patient and referred her to the committee? Does he accept the fact that physicians in their private offices with their patients may also have biases, religious beliefs or philosophical beliefs that colour their attitudes towards the problem? Why does he find it surprising and difficult to accept that a committee made up of such individuals would also have such biases? Dr. Krass seems to think that the committee is isolated from the patients, and that the patients in turn are isolated from the committee, and that this presents a problem. Dr. Krass must realize that the pattern of practice of any committee, and indeed any group of physicians in a community, quickly becomes known to all, and that the gamesmanship that has unfortunately developed in handling therapeutic abortion cases spreads quickly among all physicians in the area. A physician who does not appear to know the "rules" of this medical game is indeed naive and out of touch with what is going on in his community. I find the discussion of delay in obtaining therapeutic abortions facetious. There are waiting lists in every hospital in the country for elective and urgent surgery, often much more life-threatening to the patient than pregnancy. Potential and actual cancer patients often have to wait many weeks, if not months, before they can be investigated and managed in some of our general hospitals. Does Dr. Krass not believe they have rights, and that something should be done about them so that their "life- and health-threatening situation" can be properly managed? I am not aware of any therapeutic abortion committee that has "become extremely cautious in approving applications for abortion, due to recent attacks upon these committees by antiabortion groups and elected members of the government". Perhaps Dr. Krass could support his statement with some facts. It is my experience in talking to individuals on therapeutic abortion committees across the country, and in most of the major centres, that the committee's consideration of the application is simply to determine that the requirements of the law have been met, with one or more physicians stating that "the continuation of the pregnancy represents a threat to the life or health of the patient." If those magic words are

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used, then the therapeutic abortion committee is essentially a rubber stamp. As Dr. Krass must know, 95% of the abortions in this country are performed under the umbrella of psychiatric grounds - grounds that any physician would have a difficult time substantiating in a court of law. I find myself in agreement with Dr. Krass in one area - the present abortion law and committee situation is a farce. Whether or not the government is willing to admit it, or the medical profession prepared to state it, abortion on demand exists in Canada. That there is inequality in the availability of the service is without doubt. However, it is no different from the service for many other medical problems. T.B. MACLACHLAN, 1.1 Department of obstetrics and gynecology University of Saskatchewan Saskatoon, Sask.

To the editor: Dr. MacLachlan has raised a number of important points in his letter. I am pleased to respond to his criticisms because they require clarification and because it is important to establish a rational ongoing debate at this time, since our governments are currently considering this problem from the point of view of potential new legislation. Dr. MacLachlan's basic premise apparently is that a therapeutic abortion is a simple surgical procedure, similar to nearly any other operation in principle, so that the same rules should apply. This view ought to be demolished. It is clear from nearly any angle that this problem is not simple; it is a complex social, religious and moral issue. It deeply affects our legal system and the civil rights of our citizens. Another general position Dr. MacLachlan adopts is that the patient has many choices when applying for a therapeutic abortion. In fact (substantiated by the Badgley committee report'), usually few choices exist. Second opinions are hard to come by in this area, and time is of the essence in obtaining the needed documents while the gestational age of the fetus is still low. Distance from the therapeutic abortion committee and money are important. It is purely whimsical to suggest, as does Dr. MacLachlan, that one should naturally expect variation from committee to committee in their interpretation of the law. To have groups of legally untrained physicians attempting weekly to wrestle with a thorny legal question as it applies to an individual, generally using a few written consultations, seems totally absurd. Dr. MacLachlan admits that the majority of therapeutic abortion applications are approved for reasons that may be legal-