Putting choice back into the pro-choice movement

Jodi Magee, thank you for stating so clearly that Physicians for Reproductive Health continues to ‘absolutely support the right to choose’, despite having dropped the word ‘choice’ from its name (see Jodi Magee’s spiked article here). In the UK, we are the poorer because no organisation quite like yours exists here.

For us, reproductive health is now pretty mainstream. Our Royal College of Obstetricians and Gynecologists (RCOG) has a faculty dedicated to it. But we have no mainstream, national organisation with professional clout and profile that stands up for a woman’s right to choose.

Maybe this is why I’m alarmed when I read people arguing that the concept of reproductive ‘choice’ is passé and that we should instead adopt a language of health and justice. And maybe this is why I must seem pedantic, mulish and annoyingly intransigent when I pick up on this issue.

For me, though, it is more than a matter of semantics. ‘Choice’ means something specific. As I tried to explain in my spiked essay, ‘Remaking the case for a woman’s right to choose’, personal, individual ‘choice’ in reproductive decision-making is something special and particular. It relates to the matter of ‘who’ can make a decision, which refers to the ‘agency’ and ‘autonomy’ of individuals. When we talk about reproductive choices, we refer to the private matters that each of us must be able to resolve for ourselves. This is more than ‘health’ and extends even beyond equality and justice.

Perhaps here in the UK, some of us feel the importance of reproductive choice because none of us has ever known it. Regardless of our wealth, education or standing, none of us can have a legal abortion in Britain because we decide, personally and for ourselves, that it is right. British abortion law and practice has never acknowledged women’s reproductive choice. Our legislation was drafted in the 1960s to create the conditions where abortion could be delivered safely and regulated closely for the public good; that it should be a right for women was not even discussed. (Law professor Sally Sheldon documents this well in her 1997 book, Beyond Control: Medical Power and Abortion Law.)

Our parliament, courts and medical professionals have never accepted that women have the capacity to decide about abortion for themselves at any stage in pregnancy. Instead, the law offers a legal defence for a doctor who decides an abortion is best for a woman’s health. As a newspaper noted in the late 1960s, bishops, peers and doctors supported the Abortion Bill because it ‘will give doctors the freedom to make the best choice for the mother, her established family and the embryo within her’ (Daily Telegraph, 11 January 1967; emphasis added).

That legacy of medical patronage remains today. Even now, an abortion is unlawful unless two doctors certify ‘in good faith’ that it meets grounds relating to a woman’s health.

This means we have a law that allows for the protection of the health of the pregnant woman but denies her the right as a person to decide on her own reproductive destiny. A doctor can agree to an abortion because the woman’s health will be damaged by her pregnancy, but not because she simply does not want a baby. A doctor can agree to an abortion because she believes her patient’s fetus is at severe risk of a serious abnormality, but not because her patient does not want to have a child who has Down syndrome.

Our law works for women because our doctors frame unwanted pregnancy as a medical health issue. They say that denying an abortion is bad for mental health, or that statistically birth is riskier than abortion. And of course, this is true. But any ‘pro-choice’ doctor will tell you that they find this demeaning and degrading. It’s a fragile and tenuous framework in which competent and capable women must claim they ‘cannot cope’ with a child.

‘Choice’ cannot simply be folded into the fabric of health because not all of the choices we need to defend are those that accord with our views of health – sometimes they are just about what people want.

It has been argued that abortion is seldom a matter of choice; choices are never ‘truly free’ but rather are shaped by circumstances, we are told. But consider this: a pregnant woman with a diagnosis of Down syndrome, offered an abortion and struggling to decide her pregnancy’s future, may feel she has ‘no choice’ as to her decision. But she has a different sense of ‘no choice’ to that of a woman who literally has ‘no choice’ because such an abortion would be illegal. The one thing worse than having to decide between two things you don’t want is not being able to decide at all.

Jon O’Brien of Catholics for Choice puts it well when he explains how our circumstances, our access to resources, give context to our decisions but do not fix them for us: ‘Choice, at its core, recognises that oppression influences, but does not dictate, our choices. By grounding itself in the idea that each person has a right to bodily autonomy, to determine the course of his or her reproductive life regardless of circumstance, choice respects individual conscience.’ This is an important point, because not all women in the same circumstances will want the same thing. It is important because the decisions that we make express what we feel and who are.

We, each of us, make decisions according to our values and this is important to us. The decision a woman takes that she cannot bear another child because it will impoverish her family may not feel like a ‘choice’, but it is a decision of a different order to a decision by her doctor that she cannot bear another child regardless of what she, the woman, wants. It matters who takes the decision: agency is everything – even when the outcome of the decision is the same. A woman who decides her poverty means she must have an abortion is in a different situation to a woman who is told she must have one. Society removes personal decisions from those who are not competent to make them – when decisions about abortion are taken away from women, the status of competent, rational adults is taken away, too.

The value that doctors accord to choice – that is, to women’s autonomy – shapes the way we are treated. When you value a woman’s choice, you respect her right to make a decision you think is wrong, perhaps a less-than-healthy choice, but one that is nevertheless hers and not yours. Here in the UK, we increasingly see peoples’ choices narrowed because someone else decides what is right for them. Emergency contraception is under-promoted and overpriced lest women should choose to rely on it too much. Long-acting contraceptives are promoted heavily because doctors agree they are ‘better’, and doctors are concerned that some women continue to choose less effective methods of contraception. Regulatory guidance tells us that women should leave our abortion clinics with a method of contraception, regardless of what the woman wants.

Choice does not necessarily have to be in the name of an organisation. But it needs to be at the core of our values, because respect for women’s capacity to decide really does matter.

To borrow again from O’Brien: ‘To be pro-choice is to dedicate oneself… to making the legal, political, social, and economic changes necessary to ensure that this true freedom of choice is available to each person. Choice does not negate social justice; indeed, we believe that true freedom of choice compels us to advocate for policies that ensure that everybody, regardless of their situation, has equal access to safe, compassionate, and comprehensive reproductive healthcare options.’

For the first time in decades, in the UK we are starting to engage a new generation campaigning for choice. The notion that people should, and can, have the freedom to make destiny-changing decisions for themselves is a very big idea. It needs a very big voice, and so I am glad to hear Jodi Magee say that Physicians for Reproductive Health is still part of the choir.

Ann Furedi is chief executive of bpas, the British Pregnancy Advisory Service.