To the Editor: de Crespigny and Savulescu1 criticise legal and media attention given to the abortion of a 32-week fetus with suspected dwarfism in a case in which the expectant mother had become suicidal. At the same time, they appeal to populism to support legislative change in favour of easier access to late-term abortion.

This paradox raises an intriguing point about public opinion and medical ethics. How can members of the public develop opinion unless they are told what is going on? The case was made known to the public (although the patient’s name and face were not shown) because a newspaper editor considered it to be of great interest to many people. The public rightly has an interest in this tragic case, as it relates to at least three controversial themes of significance to public and social health — disability, suicide and abortion. Unfortunately, in recent decades, balanced and informed debate about abortion has been lacking. Instead, the issue has been portrayed simplistically in terms of a woman’s “right to choose”, with little research into the desperate and often coercive circumstances and the harmful consequences of those choices.

That late-term abortions are subject to unclear and complex state laws is testament to the fact that abortion is far from a closed case for the public, healthcare professionals and politicians. de Crespigny and Savulescu acknowledge that the case raises “profound and divisive ethical issues”. Yet, they later assure readers that the case “appears to be ethical”, adding to their overall implication that, if only Australia’s laws were clear, uniform and liberal, the media and the public would not have had any business in the matter.

Many aspects of the doctor–patient relationship are regulated by legislation — an “intrusion” that is accepted in jurisdictions in which democracy and state-funded healthcare coexist, and necessarily so, to protect both doctor and patient. If legislative change is to occur, public consultation must be sought, and the public must be given more, not less, information about abortion.

To the Editor: The article by de Crespigny and Savulescu is certainly thought provoking and timely. The harms they cite as caused by an uncertain legal environment are lamentable, although the outcomes were probably the result of multiple factors in addition to the justice system.

To bring order, reason, compassion and justice to a clinical problem as complex as termination of pregnancy — especially late termination — requires a framework for decision-making. This should operate at the hospital level, at the national level among the professionals involved, and, as de Crespigny and Savulescu contend, in the national legal system.

Most hospitals have now developed consistent guidelines to assist clinicians and patients in decisions regarding pregnancy termination (in the past, there was significant intrahospital diversity and uncertainty). More recently, clinicians involved with late termination of pregnancy for fetal abnormality in eight centres in six states and the Australian Capital Territory met in Melbourne to develop a consistent national set of guidelines. There was adequate consensus to produce a document that will soon be submitted for publication for wider community comment. Hopefully, this will facilitate better outcomes for all and perhaps even provide a stimulus for review and consistency of abortion laws.

In reply: Reti is correct that the outcomes of the late abortion case probably resulted from multiple factors in addition to the justice system. A pivotal one was the decision to divulge confidential patient information before there had been a thorough internal review.

It is pleasing that hospitals are developing consistent guidelines, although, as we indicated in our article, these guidelines should not include responsibility for clinical decision-making by committee. The responsibility for clinical decision-making should reside with the doctor, and committees should have a purely advisory role.

Consistent national professional guidelines are needed. These could be a stimulus for law reform. Without reform, it is only a matter of time before a single complaint about a case leads to a similar succession of adverse outcomes.

Ewing writes that we “criticise legal and media attention given to the abortion”. We have no criticism of the media attention and would not presume to criticise the legal processes. Our criticism was of the “decision to expose the events to legal and media scrutiny”. That is, we criticised the decision to expose the case and those involved before a thorough internal review had been conducted. We support transparency and believe that secrecy in relation to medical procedures is contrary to public interest.

We agree with Ewing that public consultation must be sought before legislative change. But one thing is clear — abortion law reform is essential. It is unacceptable that, in some cases, such as the late-abortion case we described, doctors may be charged with an indictable offence whether they agree to perform the abortion or not — under the law on abortion or child destruction if they agree to abortion, or under the law of homicide by negligence if they refuse abortion and the patient subsequently commits suicide.