303

PSYCHIATRIC ASPECTS OF ABORTION IN HONG KONG K. SINGER MD FRCPE FRCPsych. FAPA Professor and Head, Department of Psychiatry, University ofHong Kong for human life is, of course, central to the medical profession’s selfand is common to all cultures. However the extension of such a to the foetus in utero, that is contained in the Hippocratic oath and in the 1947 Declaration of Geneva, is characteristic of the Graeco-Christian tradition and is by no means universal. Be that as it may, we are now witnessing a trend towards wider legalisation of abortion, that cuts across culture, economics and philosophy. From the time the first major liberalisation of abortion laws came into effect in Russia in 1920, to the time American women gained sweeping rights to terminate unwanted pregnancies in 1973, a revolution has started, relentlessly gathered momentum and now, in many countries, reached its watershed.* But its ultimate meaning and outcome remain uncertain, and its reverberations will be felt not only in the hospital and clinic but in the very fabric of society for some time to come. Yet the basic arguments over the logic and ethics of abortion are far from over. Furthermore, the issues surrounding abortion reflect larger issues that increasingly face the medical profession, particularly with regard to its continually evolving role in relation to society. In these circumstances, enquiries into the ways in which the many aspects of abortion-legal, social, ethical, cultural, psychological and medicalvary in different countries give the subject perspective. I therefore think it worth while to discuss some of these aspects as they pertain to Hong Kong.

RESPECT concept principle

THE PROBLEM AREA

Hong Kong is a Colony of the United Kingdom. It has an estimated population at the end of 1972 of just over 4 million of whom 98~% are Chinese. The main religions are Taoism and Buddhism, with Christianity accounting for 10% of the population. The point is that pervading all the religions and the social fabric is Confucianism, which is essentially an ethical code. Added to all this is a higher amount of social pathology than is found in most western countries, in the form of economic stress, overcrowding, and social disorganization, due to a very rapid pace of influx of refugees, urbanization, industrialisation and westernization in the last two decades. CULTURAL ASPECTS

Chinese culture is complex, even in a microcosm such as Hong Kong, and simple generalisations on traditional Chinese ideas on abortion can be made only with extreme caution. Nevertheless it is probably safe to say that traditionally the Chinese have rarely even contemplated the idea of abortion, except in extra-marital pregnancy. This is due to Confucian influence, which placed a high value on the large family. For a long time the belief prevailed that having many sons and daughters meant greater happiness, more security in old age, and greater certainty that the family name and line will be perpetuated. It was common to arrange marriages of youngsters in their late teens and for old people to urge them to reproduce with all possible speed. When the Chinese did consider abortion however, they were free become practically fully United States and Russia. China, India, thehave * Abortion laws

liberalised in the four

most

populous countries

Downloaded from isp.sagepub.com at UNIV OF MASSACHUSETTS on April 13, 2015

of the world-

304 from any moral or religious objections, such as ideas of whether it meant destroying unborn life. They were therefore not afflicted with the deep questions of personal conscience and the guilt that have characterized the attitude in the west. In many ways, especially in matters of religion, the Chinese are not dogmatic but pragmatic; in abortion they are concerned mainly with the physical dangers. We may therefore conclude that, in general, the Chinese culture placed no obstacles in the way of accepting abortion as a solution to social and personal problems. In the last one or two decades social conditions and philosophy have steadily changed under western influence. Hong Kong has now achieved the same essential conditions, though not necessarily to the same degree, as exist in the west, conditions that form the basis for a more liberal attitude to abortion. Thus in Hong Kong the old idea about the value of a large family is no longer predominant. A recent survey, for example, has shown that three quarters of all urban married woman do not want more children.* Then, higher standards of living and education have brought with them the expectation of an improved quality of life, which, it is realized, may be secured by family planning. Then again, the gradual movement in Hong Kong towards equal rights for women can only enkindle a greater desire on their part to control their lives and their bodies. Finally, the ready availability of simple and safe techniques for abortion has made it a practical consideration. Public opinion regarding the law on abortion is no doubt gradually evolving towards greater liberalisation, though it has not reached the point of demanding abortion on request. However, the law has not kept pace with public opinion and several reasons for this may be given. Firstly the public because of the special status of Hong Kong, tends to avoid, or at least to make itself heard, on political issues. Secondly the colonial government is reluctant to go against what it regards as local tradition, as a matter of policy. Finally, illegal abortion is easily obtainable anyway, except by the economically disadvantaged, who, however, are not known to be parti-

cularly vocal.

LEGAL ASPECTS

Up until 1972 the law, strictly interpreted, allowed termination of pregnancy by qualified medical practitioners only to save the life ofthe mother. Whether it allowed termination to prevent serious injury to the physical or mental health of the mother was not entirely clear. There was no provision in the law for termination on eugenic, social, economic or humanitarium grounds. In 1972, new legislation dealing with abortion, including therapeutic abortion, was introduced in the Offences Against the Persons Ordinance. The provisions follow the U.K. Abortion Act, 1967, in making abortion legal if &dquo;two medical practitioners are of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman or of injury to the physical or mental health of the pregnant woman greater than if the pregnancy were terminated&dquo;. That is, abortion is made legal if it would lessen the risk, not only to the life, but also to the health, physical or mental, of the mother. The law does not go as far as the U.K. Act in that there is no provision for termination on eugenic grounds, namely risk of the child being born with abnormalities, physical or mental. Nor is there any provision for termination on grounds involving risk to the existing children of the pregnant woman-i.e., risk to their health, physical or mental. There is also no concession in the Hong Kong law to emergencies, such as in U.K., where in such circumstances only one doctor’s recommendation is required. The law also stipulates that the abortion must be carried out in a hospital or clinic maintained by the Crown ’~It is of interest that in China the

officially favoured

size of the

family

now

is

two

children.

Downloaded from isp.sagepub.com at UNIV OF MASSACHUSETTS on April 13, 2015

305

specially approved for the purpose. Although it is too early to say how the new law will work, the Attorney General has already stressed that it is not intended to legalize abortion in any general way, or

that it is very limited in scope, and that it is intended to do no more than protect those who undertake therapeutic abortions in specified circumstances in approved hospitals or clinics. Introduction of the law has certainly not been accompanied by the provision of extra facilities such as abortion clinics to cope with any expected rise in requests for abortion. The Hong Kong law is therefore considerably less liberal than the U.K. law, which in turn is somewhat less liberal than that of the United States. Nevertheless undoubtedly the Hong Kong law has been liberalised to an extent. Specifically, it has eased the medical requirements in allowing for abortion on grounds not only of risk to the life, but also of risk to the physical and mental health of the woman. And it has provided for abortion on social and economic grounds for the first time, strict though these may be, in allowing for the woman’s &dquo;actual or reasonably foreseeable environment&dquo; to be taken into account in determining the effect of pregnancy on physical and mental health. It is interesting to contrast the situation in Hong Kong that in China today, where abortion is allowed on request in the first three months of pregnancy (though the authorities try to persuade a childless woman to have her first baby). CURRENT PRACTICE

In consequence of the until recently very strict law many doctors have been reluctant to involve themselves in abortion, at least openly. In practice therapeutic abortion has been performed on grounds of severe disease and has sometimes taken into account socio-economic circumstances. However, only a very small proportion of abortions have been carried out openly in this way. It remains to be seen what effect the new legislation will have on the number of requests for abortion. For the vast majority of those wanting an abortion and able to afford it there is in fact little difficulty in getting this performed by a competent medical practitioner. The majority of abortions are probably carried out by medical men. It is not possible to estimate the number of illegal abortions performed annually but the rate may well be similar to that in Western countries with strict laws; I have no data however to support this opinion. The vast majority of women seeking abortion are married as the incidence of extramarital pregnancy is low. PSYCHIATRIC INDICATIONS

How then are we to interpret the new law in terms of psychiatric indications for abortion ? Any such interpretation must take into account certain considerations : 1. There are no absolute or universal psychiatric indications for termination, but they vary according to local laws, customs and attitudes. So far as Hong Kong is concerned the letter of the law is, as I have pointed out, 2. still comparatively strict, but local attitudes are more liberal. I will now give some idea of how I would translate the law into clinical practice. One bears in mind that a high degree of subjectivity is involved in such an exercise; also each case must be individually considered. I would use guidelines such as the following : &dquo;Termination is likely to be indicated in the psychoses and in the severer forms of mental deficiency; it is not likely to be indicated in the neuroses. The grounds for termination would gain added strength if the psychiatric condition existed prior to pregnancy, and especially if it was aggravated by previous pregnancy. Regardless of the foregoing, the existence of adverse psychological and social circumDownloaded from isp.sagepub.com at UNIV OF MASSACHUSETTS on April 13, 2015

306

depending on their severity, may override other considerations. I have in mind particularly the risk of suicide, economic hardship and the lack of support from relatives. I would also give special consideration to the unmarried mother, because of the particularly severe cultural stigma involved. There should be no problem with abortion for pregnancy following incest and rape.&dquo; These then are some very rough guidelines, and they may appear rather indefinite, but it is difficult to be more definite when the law has been left deliberately vague. A nice case would be the previously mentally normal woman who wants tennination for personal reasons and becomes distressed with the prospect of not being able to obtain it. It could be argued that such distress constitutes a risk to mental health, no matter how slight. Failure of contraception could also be put forward as a physical ground for abortion. Yet to accept such arguments is to allow abortion on demand which is clearly not the intention of the law. stances,

CONCLUSION

faces an abortion law in Hong Kong, and in may other parts of which has enmeshed social, economic, moral and psychological problems with the physical. As only physical problems have traditionally been our area of concern, the law raises crucial issues for the medical profession-namely, the extent to which the profession should regard social and related problems as within its province, and its competence in dealing with such problems. There are still those who would prefer the narrow ’disease’ model of health. Yet in spite of much controversy we are gradually moving towards a much wider model, as witness the WHO’s definition of health. Psychiatrists have of course, never been guilty of holding a narrow conception of health or the professional role. Others have pointed out that psychiatrists have a vested interest in doing so, since limiting themselves to organic pathology would greatly restrict their scope. Nevertheless it must be conceded that a wider concept of health benefits primarily the patient. Moreover, other branches of the profession are also facing an increasing numbr of situations involving social and psychological problems, e.g. family planning and genetic counselling. If therefore we agree to take a broad view of health, we should acquire adequate knowledge of, and a responsible attitude towards, all the forces that shape the human condition-be they physical, psychological or social. Only then can we deal rationally and effectively with the increasing number of multifaceted problems that confront us, such as the problern of abortion. The

the

profession

world,

Downloaded from isp.sagepub.com at UNIV OF MASSACHUSETTS on April 13, 2015

Psychiatric aspects of abortion in Hong Kong.

303 PSYCHIATRIC ASPECTS OF ABORTION IN HONG KONG K. SINGER MD FRCPE FRCPsych. FAPA Professor and Head, Department of Psychiatry, University ofHong Ko...
285KB Sizes 0 Downloads 0 Views