On November 17, 2022, the British government updated the figures for abortions carried out in England and Wales in 2021. These figures put into context the present debate about the introduction of abortion in Malta.

They are unemotional statistics giving stark numbers of lives lost.

In England and Wales, 214,256 abortions were carried out in 2021 but only 111 were because it was necessary to save the mother who was at serious risk of dying or of serious injury. Of the rest, 98 per cent (209,939) of the abortions indicated a risk to the woman’s mental health as justification for the intervention.

This risk to mental health was usually classified as F99 (mental disorder, not otherwise specified).

Hence, doctors in England often attempt to strike a balance between the life of the foetus and the health of the mother and decide that the risk to the health of the mother caused by the mental difficulty of an unplanned pregnancy is more dangerous than continuing with the pregnancy.

In Malta, the words proposed by the government legislator are “risk of putting the mother’s health in grave jeopardy”. The problem with this formulation lies in the nature of the relationship between the doctor and the patient during the consultation.

The doctor-patient relationship is one of trust. The consultation is “the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts”. It is this trust between doctor and patient which is at stake in the present debate on the introduction of abortion into Malta.

The present government proposal puts a doctor in the difficult position of having to strike a balance in his mind bet­ween the life of the unborn child and the health of the mother, so as to decide whether the risk to the mother’s health outweighs the life of the child.

Doctors require a time limit so as to know at what point in the pregnancy they can intervene- Mark Agius

According to the proposal, the doctor must come to this decision without the support of any other doctors – since there is no other doctor or expert mentioned in the legislation – and even if the child could live on its own, since there is no limit of time during the pregnancy mentioned in the legislation.

The doctor is used to being an advocate for the patient. He must now be party to a very difficult decision which he must carry out objectively, whatever the expressed wishes of the patient.

Given the pressures that I have described, it is not surprising that there is a likelihood that doctors may give in to the pressure and choose to agree that the patient’s illness is sufficiently grave to justify an abortion, with the same results as have been experienced in England and Wales.

Thus, this proposal changes the relationship between the doctor and the patient. This is why, if the legislation is to be changed, doctors require parameters in the legislation which form the context for such a decision.

They require clear, legally binding guidelines as to what is legal and what is not. They require a time limit so as to know at what point in the pregnancy they can intervene.

They require legally binding guidance as to who they must consult with before carrying out an intervention.

They require a system by which they can be supported if they feel that morally they cannot intervene, either because their moral beliefs do not allow them to do so or because in a particular case they do not feel that the risk to the mother’s health is sufficiently grave to warrant intervention.

The present proposed legislation offers none of the above prerequisites for the implementation of the policy which it proposes to promote – that of allowing the termination of a pregnancy only if the life of the mother is at grave risk, while all other prohibitions on abortion are kept in place. Rather, it is likely to lead to both medical and legal confusion.

On the other hand, the version of the legislation proposed by a group of academics does give the beginning of a framework which provides the context within which doctors can safely come to decisions about an individual case.  What is needed is for time to be taken for discussion so that a national consensus is formed and then for legislation to be produced which covers all the points I have mentioned here.

It is possible that, when all facts are taken into account, the legislation does not, in fact, need to be changed because the current law gives sufficient guidance.

Meanwhile, it needs to be pointed out that, in these difficult cases, internationally accepted guidelines will always advise that great care is taken in adjusting the treatment of the mother’s health conditions during the pregnancy in order to achieve the best possible outcomes for both mother and child. This is true in both mental and physical conditions.

We need a way of working in which doctors and patients can collaborate in such a way that we, the people of Malta, can live in a society which promotes both healthy mothers and healthy children. This is the aim of good medicine.

Mark Agius is a retired doctor. He is a writer on medical management, the doctor-patient relationship and psychiatry. He has taught at Cambridge and Prague medical schools.