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I wrestled even with the “easy bit” of this routine procedure, accessing her cervix with the suction curette.
I watched heterogeneous pregnancy tissue whoosh into the vacuum container, well differentiated and

1
multicoloured, unlike the whitish placental tissue of early abortions. Anyone withimagination
any will see
this for what it is: pieces of fetal organs
and blood vessels. I admit I often feel distaste at this.

Violence of the procedure

This time, the tissue clung tightly to the uterine wall and Itohad make many passes with the suction
curette to remove it. A
large piece removed with sponge forceps would not pass the down
tubing even
with the tip removed. I found myself—saw myself—battling, literally, to push the pregnancy of a woman
who was reluctant to terminate down a suction curette with gloved
my hands.

The violence of this situation struck me keenly. Perhaps Ia felt

bit like the perpetrator of systemic
violence—the brutal armof the state removing a pregnancy from a woman who, given other
circumstances, would have liked to keep it. Perhaps Iviolated
felt too. An involuntary wave of physical
revulsion passed through me, and, on my surgeon’s stool between the woman’s
surgically draped legs, I
felt tears quietly run down my face.

The moment passed quickly. I inserted an intrauterine contraceptive, descrubbed, signed out on the
computer,composed myself, and documented the procedure in brief, technical terms, bypassing, as
healthcare practitioners
conventionally do, the subjective or interpersonal aspects of
encounter.
the

But what do we make of a gynaecologist unexpectedly weepingover a difficult termination in a woman

who felt forced toterminate? Or put another way, of an emotional response asserts
that itself unusually
within a professional routine? I am aware
that my story could most conveniently be suppressed. In being

told, it could be retrofitted into various pre-rehearsed arguments about abortion and politics. If you
wanted to use it to confirm prior beliefs, you could make this a story about the evils
abortion,
of or the
wrongs of the current immigration and benefit system, or an indictment of one doctor’s oversensitivity, or,
as I have chosen to see it, about the importance of reflection.

I know little, actually, about the circumstances of my patient’s residency in the UK or benefit entitlements,
only that she was under a degree of existential duress that was difficult to distinguish from coercion; and
that I found the physical fight with the resistant pregnancy tissue hard to stomach. I do not in the end feel
harmed or shamed by the procedure, or the shedding of a few tears over it, but I am clear about my need
for preoperative, and in this case postoperative, reflection.

What I see in my story is the responsible, vulnerable human practitioner at the heart of all healthcare. No
matter what our technical competence and experience, we stand and fall on the quality and integrity of the
processes we work within, and on one another. Whatever the law says, I have no ultimate moral defence
that what I was doing on that occasion was “right.” Rather, I depend on the grace of colleagues and
systems which work in reflective, humane, conscientious ways and on my capacity for conscientious
reflection.

Respect for the integrity of all parties

Abortion is a sensitive area for all concerned. It is not surprising that many practitioners choose to avoid it
for emotional and aesthetic reasons, even if they do not hold religious beliefs that oppose it, and we should
not blame them, as long as they do not act in ways which disadvantage patients.2 But those who choose,
for humane and ethical reasons, to perform abortion, need a context in which to work that respects the
integrity of all parties.

A woman n eeds space to explore any ambivalence in relation to the potential life, which no one feels more

2
keenly than she does, without fear of losing her autonomy. This is true whether she is able to bring it to
fruition or not.

To avoid brutalisation, abortion should not be offered on a conveyor belt but through a reflective process.
We will not achieve this by criminalising abortion, overpowering women’s autonomy over their bodies, or
pretending that healthcare practitioners, politicians, or religious leaders can know what is best for
individuals. Rather, we need structures and processes which support shared conscientious reflection. So
that when the tissue is distressingly hard to remove, the practitioners involved know due process has been
served. And when it is gone, and the woman wakes up, she knows it too.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I
am a member of an Anglican church.
Patient consent not required (patient anonymised, dead, or hypothetical).
Provenance and peer review: Not commissioned; not externally peer reviewed.
1 Antonovsky A. Health, stress and coping. Jossey-Bass Publishers, 1979.
2 Kasliwal A, Hatfield J. Conscientious objection in sexual health—a guideline that respects diverse views
but emphasises patients’ rights. BMJ Sex Reprod Health (forthcoming).
doi:10.1136/bmjsrh-2017-101853.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under
a licence) please go to http://group.bmj.com/group/rights
UK abortion is regulated by criminal law

Unlike in many European countries, abortion in the UK is regulated by criminal law. For an exemption to
apply, certification is required from two doctors that there is as a minimum a greater risk of harm to the
mental health of the mother if the pregnancy is continued than if it is terminated.

The BMA, the Royal College of Obstetricians and Gynaecologists, the British Association of Abortion Care
Providers, the British Pregnancy
Advisory Service, Marie Stopes UK, and the Royal College of Midwives
are campaigning for decriminalisation of abortion in the UK.Faculty
Th of Sexual and Reproductive
Healthcare is due to vote on the issue on 23 November.

Biography

Sandy Goldbeck-Wood is a trainer for the Institute of Psychosexual Medicine, which, in common with
several other disciplines, sees practitionerself reflection as an essential source of information about the
clinical encounter. As editor in chief of BMJ Sexual and Reproductive Health (formerly the Journal of
Family Planning and Reproductive Health Care), she has argued that both practitioner and patient
subjective accounts have a place in the health debate. This article was adapted from a piece of writing used
to reflect on practice while clinical lead for an NHS
abortion service
.[BMJ, Nov. 2017]