Pregnant with confusion

So now a woman has conceived eight children and is determined to have them all, whatever the cost. The consternation the case will probably cause is a curious mirror to the one publicised last week. In that, a pregnant woman decided to abort one of her healthy twins on the grounds that she could not cope with bringing up both. And just as the earlier case posed some awkward questions for those who favour abortion, so the case of Mandy Allwood will put those who oppose it on the defensive.

The case of the woman who only wanted one of her twins threw into confusion the comfortable assumption that, as a society, we have the abortion issue under control. It brought us up against the fact that abortion on demand, even of perfectly healthy foetuses, is now largely available in the UK, and that in such a situation arbitrary decisions will be made.

For all but the most extreme pro-choice triumphalists, that is a discomforting thought - particularly for those who would support a woman's right to choose in the belief that most decisions to abort are taken seriously and for justifiable reasons. In exposing the inconsistencies of the liberal position on abortion, the case has threatened to re-open the whole abortion question, thought by most to be long settled. It has certainly required those who adopt a pro-choice position to explain why so many non-dogmatic people feel repugnance at the idea that a perfectly healthy life can be ended purely for social reasons.

In the latest case, Allwood, apparently to her great delight, has conceived eight children as a result of fertility treatment. Her doctors are advising that, since no one has yet given birth successfully to such a large number of babies, she should opt for the selective abortion of most of her foetuses to ensure the healthy delivery of some of them. This advice is accompanied by warnings about the risks to herself as well as the likelihood of severe mental handicap for any child who survives.

So far, Allwood appears to be ignoring medical opinion and is determined to go ahead with the pregnancy without selective abortion. Many people may admire the courage of someone who, despite the odds, seems willing to risk everything to bring her children into the world. But there are aspects of her behaviour that are rather difficult to admire.

Questions will undoubtedly be raised about the sense of responsibility of someone who, while undergoing fertility treatment, is advised not to engage in sexual intercourse because she is producing too many eggs, and goes ahead and does it. Her more-or-less immediate involvement with the PR guru Max Clifford, who thinks she could secure a pounds 1m deal, also leaves something of a bad taste. But despite the unedifying details of this case, it raises a similar question: is it morally acceptable to abort some healthy foetuses in order to ensure the survival of others?

The confusing thing about it is that while choosing the death of a healthy foetus looked wrong in the one case, the selective abortion of more than one - in fact up to six - in the other case merely looks like the sensible thing to do. Why do we have intuitively different reactions to the two?

It might be argued that the difference is this: the abortion of a healthy twin was made because of social considerations, while a decision to abort the Allwood babies would be made on medical grounds. If that is the explanation, those who are pro-choice in serious cases but uneasy about selective abortion for purely social reasons can rest assured in the Allwood case, because it would appear that there are good medical grounds there.

But are matters so clear? Pro-life groups claim that the judgement that it would be medically unsafe to proceed with the pregnancy involving eight foetuses is itself value-laden. It is, they say, the response of a medical profession which for the most part is convinced already of the acceptability of abortion as a medical procedure.The medical profession, they argue, seems to believe that any pregnancy is detrimental to the mother's health compared with not being pregnant; with that premise the existing law is tantamount to abortion on demand - which, whatever might be thought now, was not the intention of Parliament when the law was passed. Allwood, they say, should put herself in the hands of a pro-life doctor who would try to ensure the healthy delivery of all of her babies. If that failed, nature would take its course in aborting some of them.

The question of medical fact is crucial. If it is not strictly true that selective abortion is required to safeguard Allwood's pregnancy, then the argument for selective abortion in her case looks just as arbitrary as it does in the case of the aborted twin. If it is true that all the babies will die, before during or shortly after birth, then there is a real difference. The trouble is that if there is a fact in the matter here, no one appears to know it.

And even if the pro-lifers are correct about the medical facts, their own position is far from unassailable. It appears no more completely thought out than is the position of the pro-choice camp. For example, pro-life groups are not against fertility treatment in principle, at least where it involves natural methods of conception, but should they not in all consistency be opposed to it because of the consequences it can produce?

The pro-life position here is not morally unproblematic. Suppose Allwood goes ahead with her pregnancy against medical opinion. Why is the fact that she will almost inevitably miscarry some if not all of her children be less of a tragedy than losing them through selective abortion? What should be done if her life and the lives of all of her children are put at risk or seriously damaged by mental handicap? To that question the pro-life camp appears to have no ethically acceptable answer.

But then ethically acceptable answers are in short supply on the question of abortion. In the short-term, society may be happier with that confusion. But in the long-term, will that suffice?

The author is director of the Centre for Medical Ethics at King's College London.