Autonomy is the principle that people are capable of deciding matters concerning themselves which are free from external limitations, as society or the law may restrict individuals from being fully autonomous. The scope of this article surrounds autonomy within the law and the place autonomy holds within it. Medically, autonomy allows the patient to be the ultimate decision-maker regarding the undertaking of a medical procedure and is seen within the doctrine of informed consent. This is not reflective in abortion law as a doctor can stop those pregnant from having this procedure.
There is no right to abortion: it is a criminal offence. It is an offence for someone to procure their miscarriage, or for someone to assist the procuring of a miscarriage. However, the Offences Against the Person Act is now subject to the defence found in the Abortion Act 1967 which states (subject to certain grounds) that “a person shall not be guilty […] when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith”. Written norms are problematic as they speak from the past, intending to govern the future and how they work depend on their interpretation.
This article, firstly, argues that deconstructing the Abortion Act 1967 (henceforth referred to as ‘the 1967 Act’) illustrates that autonomy was not important when it first passed, referring to the medicalisation of abortion and the social expectation of women. While it is recognised that women are not the only ones who can get pregnant and therefore undergo abortions, this article will primarily focus on the historical analysis of the relationship between women and abortion. Although, secondly, interpreting the 1967 Act in practice can give pregnant people autonomy, albeit to a limited extent, referring to the statistical argument for sections 1(1)(a) and 1(1)(d) before 24 weeks. Thirdly, whether autonomy is seen as important in abortion law, mental health and wellbeing are ultimately promoted if a woman’s autonomy is not restricted.
Part I: Medical practitioners
To assess the importance of autonomy in abortion law, it is necessary to deconstruct the 1967 Act to understand the past constructions of women and why it took the form it did to outline whether autonomy was located at the forefront of women’s decision-making. Abortion is “medicalised” and prioritised by medical opinion with no liberalisation for women following the act: it is a defence for medical practitioners. The parliamentary debates “culminated” the passing of the Act, providing no intention for the reforms to give a woman a right to abortion but rather determined that doctors were the “gatekeepers” to a lawful abortion. Notably, Woliver outlines how pregnancy is portrayed as an illness which only medical practitioners can correct. Likewise, the disability ground was incorporated following the impact of thalidomide as it was felt inhumane to compel a woman to carry such a pregnancy to term. Abortion was seemingly framed as a treatment to counter the effect of this drug. Additionally, the view that only “a bold and brave judge would seek to interfere with the discretion of doctors” under the 1967 Act has been repeated in multiple subsequent cases, corroborating the authority which doctors held at the time of the passing of the Act. Furthermore, there was an intention to “stamp out the backstreet abortions” following serious maternal mortality, without opening the door to abortion ‘on request’. This adds to the view that autonomy was of no importance when the Act was written but was to merely justify abortion in the most serious of circumstances.
Part II: The social expectation of women
The philosophy behind this consensus is how women were perceived as incapable of deciding whether to end their pregnancy without receiving a “guiding hand” from a responsible registered medical practitioner. As illustrated by Justice Macnaughten, a 16-year-old rape victim was a “normal, decent girl”, rather than ill-defined with a ‘prostitute mind’. Similarly, women who wanted to terminate their pregnancies were described within the debates as abnormal; betraying their “natural role” as a mother. Sheldon acknowledges that they were classed as either an “emotionally weak, unstable victim of [their] desperate social circumstances”, or a “selfish, irrational child”. Parliament’s intention, therefore, was to ensure that the decision to abort was one which fundamentally did not lie with the pregnant woman. This reflects the presumption of maternity which has entrenched society throughout the decades: women are meant to be mothers. Furthermore, Priaulx recognises that these constructions of women are illustrated in textbooks, consolidating the lack of importance of autonomy within the law. Textbooks take a similar narrow approach where the wider context regarding women’s voices are absent, arguably, because society portrays a negative view of abortion, reflecting “the kind of stuff that does not look incredibly legal but gives meaning to the law”.
The purpose of the law is to ensure that women take responsibility for their actions: if the woman sidesteps the accountability of her “carelessness”, the law ought to “stand as a barrier”. The law created a “fiction” of women to justify the partial legislation of the 1967 Act. Thus, abortion is seemingly only justified in circumstances where the fulfilment of carrying out their mothering duties would be infringed. The law sympathises for those women who fit within the grounds of the 1967 Act rather than permit abortion based on the woman’s choice. Thomson recognises that this is a gross injustice in the law, considering that there is no obligation to be a “good Samaritan” unless under a duty of care, yet women are compelled by law to be good Samaritans to a foetus unless justified otherwise.
Nevertheless, the 1967 Act was passed, and it was left to medical practitioners to interpret it. Many took a liberal interpretation of the law, while others did not. For example, 70% of 170 requests for an abortion were refused in just over six months in one hospital. Another study outlined how some medical practitioners actively worked to persuade women to carry on with their pregnancy and deliberately created a delay to ensure that women fell outside the time limit. One medical practitioner explained how “most can be talked out of it”. There were also reports that women were subject to overly intrusive questioning and judgemental treatment when visiting their general practitioners. The idea that a pregnant woman should have some say over what should happen to her body could not be accepted by the majority of the profession; the fear being that women may get what they want but not what they ultimately need.
Part III: In practice
Since the 1967 Act was implemented, the idea that medical practitioners should be at the forefront of abortion decision-making seems to have “ebbed away”, at least in the first 12 weeks where the majority take place. Understandably, judgements will continue to form about the legitimacy of the woman’s reasons for abortion but it appears rare for them to lead to a refusal. This historical emphasis on a doctor’s ‘expertise’ of whether abortion should occur has shifted towards a promising focus on patient autonomy and can now be seen in recent case law. It has been recognised that patients are “now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession”. Patients are seen instead as capable adults who can understand the risk of medical treatment and can accept responsibility and the consequences of their choices. Pregnancy “does not diminish [a woman’s] entitlement to decide whether or not to undergo medical treatment”.
Lee has recognised that interpreting the law liberally allows access to abortion fairly easy to obtain, notwithstanding the fact that a woman has no right to access it. Lady Hale corroborates this and states how “the availability of legal abortion depends upon the opinion of others”. Yet, unfortunately, we return to the framing of the 1967 Act which depends upon the professional integrity of medical practitioners. Although, if an abortion is refused and the reasons are not given, it begs the question of whether a woman is aware that the 1967 Act could be interpreted differently depending on the medical practitioner. It would be hoped that she has social awareness and is informed enough to receive a second opinion. This, however, emphasises the difficulties in accessing abortion within a system where differences of opinion can occur. Thus, prima facie, a medical practitioner’s discretion determines the effect on the number of abortions carried out, especially where a liberal approach could be taken more so by some.
Part IV: Section 1(1)(a)
It has been suggested through multiple obiter comments that the law has become “wrongly, liberally construed in practice to make abortion available essentially on-demand prior to 24 weeks”. The liberal approach by doctors can come as no surprise considering s 1(1)(a) will always be satisfied. This is the statistical argument which renders conduct lawful which would otherwise be a crime; “the risk to the life, physical and mental health of a pregnant woman of continuing a pregnancy, although low, will always be greater than the risk of terminating a pregnancy”. Autonomy is, therefore, arguably protected by the ‘back door’, especially when statistics illustrate that 9 in 10 abortions are under 12 weeks’ gestation with 80% carried out at under 10 weeks. A woman will not be pregnant if she does not want to be. Nevertheless, the limit demonstrates the medicalisation of abortion, taking the decision away from the mother and focusing on the foetus. “Ultimately, the doctors must form an opinion that the ground applies to this individual and not solely on the basis of abstract statistics”. Furthermore, it would be unlikely that Parliament intended for this criteria to be interpreted in this way since it hinders the need to criminalise this section. Nevertheless, in light of this interpretation, the British Medicla Association (BMA) briefing states that “the requirement for medical criteria should be removed from first-trimester abortions”. Similarly, the House of Commons Committee supports this standpoint, advocating that the requirement is not serving to “safeguard women”.
Parliament ensured that when the 1967 Act was passed the intention was not to allow abortion “on request”. Nonetheless, the permitted broad discretion has allowed this interpretation to evolve, granting liberal access to abortion. It has arguably gone too far, as issues have been raised that abortions have taken place based on the sex of the foetus. Yet, Landsley confirms that this is illegal and emphasised that “health professionals must not think they know better than the law”. Despite this, the Crown Prosecution Service (CPS) took no further action and Starmer has acknowledged that the “law does not […] expressly prohibit gender-specific abortions”. In some circumstances, the medical practitioner may conclude that the sex of the foetus may have a detrimental effect on the woman’s or an existing child’s mental health which may be severe enough to authorise an abortion. Thus, it is not a concern whether their view is right: “if they form that opinion genuinely and in good faith, [..] there is no guilt attached to it”. Additionally, the choices women make are a result of the circumstances they find themselves in and their autonomy should not be restricted because of that. However, following the outcry of possible abortions permitted on the sex of the foetus, the British Pregnancy Advisory Service (BPAS) outlined that the medical profession is now “nervous” in everyday practice as the lines are blurred to what is legal and illegal. Likewise, the CPS noted how there is no guidance for medical practitioners regarding the assessment of risk for a pregnant woman’s physical or mental health and it became apparent that there is “no generally accepted approach among the medical profession”.
Part V: Section (1)(1)(d)
Nevertheless, s 1(1)(a) can implicitly be used for selective abortion where a woman fails to succeed on the disability ground and allows weight to be given to women’s concerns. Thus, if a woman proclaimed that she cannot accept the risk of probability of a disability while her medical practitioner considers the disability less than serious, the decision to abort could be justified to protect her mental health. This, therefore, provides the autonomous choice to a woman through “sidestepping” the requirements that the risk of a disability must be serious and substantial. This has been proven by the statistical argument above. As Scott argues, one way to interpret s 1(1)(d) for abortions before 24 weeks is to consider it alongside s 1(1)(a) and is unclear why we would appeal to s 1(1)(d) in this instance. The conflict of interpretation seems to surround the lack of honesty regarding whose interests the disability ground of the Act protects. Nevertheless, it seems that the pressure to use s 1(1)(a) follows from the lack of a rights-based system in our jurisdiction. It is seemingly unjust to restrict a distressed pregnant woman from an abortion just because their disability has not been found by medical practitioners as sufficiently serious to justify it. Consequently, abortion in practice gives some weight to a woman’s view within this context, where the importance of autonomy within the law is seen indirectly.
Aside from parental interests which relate to the impairment, some parents may have underlying interests relating to the harms of social discrimination. Yet, Sheldon and Wilkinson note that this argument is not entirely successful, considering the disadvantages associated with disability are partly caused by impairment. These become ignored when the focus is on social discrimination: for example, if you are blind or cannot walk, you will fundamentally have an impairment. Arguably, it is necessary to make thorough distinctions between disabilities involving reasonably minor impairments stemming from social discrimination and where disabilities have more extensive impairments which would be significantly damaging even without considering the contribution of social discrimination. Alderson conducted multiple interviews with individuals who have several different conditions. The results illustrated that the individuals suffered more from social stigma than their physical disorder: a presumption linking disability and suffering should not be made. To assert that a woman wanting to abort due to serious foetal impairment is a representation of invoking her autonomy simply upholds her entitlement to have a say on how her own reproductive experience should take place. People can decide whether they wish to reproduce and should thus be allowed some control over the child that will be born. Nevertheless, the choice to reproduce represents a drastic difference since the implementation of the 1967 Act where it was abnormal if a woman did not conceive. Thus, perhaps a more appropriate method is to focus on the education of disability more widely instead of restricting autonomy and dismissing it through the 1967 Act.
Part VI: Mental health
Seemingly, whether there are restrictions on abortion, or it is interpreted liberally, autonomy is not important for women. Sarah Catt, following the birth of two children from complicated pregnancies, presented for an abortion on her third pregnancy but it was late and was therefore refused. She then bought pills online and aborted a full-term 38-week-old foetus and was sentenced to 8 years in prison but was reduced to 3.5 years on appeal. Despite a rare case of prosecution, it emphasises that abortion is still a criminal offence and that women do not have a right to abort. Yet, women will continue to abort regardless of the laws in place.
While this may be liberalising for women in a sense, restricting a woman’s right to bodily autonomy will nonetheless have a damaging effect on a woman’s mental health and wellbeing when forced to carry a pregnancy to term. Out of 500 mothers, those with unwanted children were “substantially more depressed” than other mothers. Dagg further found that those denied abortions will experience permanent unwanted feelings towards a child as a result. Adoption has been suggested as a plausible alternative to alleviate this problem, yet mental health problems still occur following the placement of a child for adoption; depression and extensive loss. As a result, women usually experience positive feelings following an abortion procedure. Following an eight-year study involving 5000 women, Russo and Zierk found that those post-abortion “had higher self-esteem in general and greater feelings of worth”. Similarly, the majority of patients experienced mood improvement. One woman expressed: “I made the right decision. Was the embryo inside me life in some form? Yes. Was it the equivalent of adult life such that its rights should have exceeded mine? No”. Surprisingly, laws restricting access to abortion are discriminatory; forcing women to engage in childbearing which brings simultaneous negative financial and health implications. Therefore, as Grimes suggests, “[w]hen abortion is made legal, safe, and easily accessible, women’s health rapidly improves. By contrast, women’s health deteriorates when access to safe abortion is made more difficult”. Thus, whether autonomy is important in abortion law, if women can express their liberty through choosing an abortion their mental health and wellbeing are promoted.
Britain has moved away from treating abortion as a criminal offence and gradually shifted towards a position where abortion services are becoming an essential part of reproductive healthcare. The continuance of these ongoing restrictions in the law is difficult to justify for women and their autonomy. Erdman observes no connection between rates of abortion and its legal status: criminalisation does not result in the prevention of abortion. Therefore, regardless of the details of reform, this article has outlined that the current law on abortion is an “anachronistic remnant of the attitudes of a previous age”. Reform is necessary to create a framework which fits current norms similar to other areas of medical law, recognising the importance of autonomy. As Sheldon argues, the fact that a pregnant woman can refuse treatment placing a 36-week-old foetus at risk but is inhibited from aborting a much younger foetus because of the limitations in the 1967 Act is illogical.
Despite the lack of reform made to the 1967 Act which has surprisingly “survived largely unchanged since 1967”, abortions are authorised within a radically different medical context. The reality seems that within the first 24 weeks of pregnancy, the interpretation of the Act has led to increased recognition of the importance of autonomy interests within the law. Nonetheless, abortion law in England and Wales cannot be considered legislation of a liberalising measure for women. The Act does not refer to the rights of women who decide to abort. Thus, women are offered greater access to abortion in practice despite what the Act appears to outline. Reform must reflect this.
 Offences Against the Person Act 1861.
 Ibid s 58.
 Ibid s 59.
 Abortion Act 1967, s 1(1).
 Julia Black, ‘Regulatory Conversations’ (2002) 29 JLS 163, 172.
 Ellie Lee, ‘Young Women, Pregnancy, and Abortion in Britain: A Discussion of Law in Practice’ (2004) 18 Int J L Policy Family 283, 285.
 Abortion Act 1967, s 1(1).
 Samantha Halliday, ‘Protecting Human Dignity: Reframing the Abortion Debate to Respect the Dignity of Choice and Life’ (2016) 13 CIL 287, 302.
 Laura Woliver, The Political Geographies of Pregnancy (University of Illinois Press 2002) 30.
 See Keith Hindell and Madeleine Simms, ‘How the Abortion Lobby Worked?’ (1968) 39 Polit Q 269, 276.
 Sheelagh McGuiness, ‘Law, Reproduction, and Disability: Fatally ‘Handicapped’?’ (2013) 21 Med L Rev 213, 226.
 Paton v BPAS  QB 276, 282 (Sir George Baker P).
 See C v S  QB 135, 153.
 David Steel, Medical Termination of Pregnancy Bill (HC Deb vol 732, July 1966)
 Halliday (n 8) 320.
 R v Bourne  1 KB 687, 694-695.
 Halliday (n 8) 302.
 Sally Sheldon, ‘Who is the mother to make the judgment? The construction of woman in English abortion law’ (1993) 1 Fem L S 3, 6.
 Nicky Priaulx, ‘The social life of abortion law on personal and political pedagogy” (2017) 25 Med L Rev 73.
 Ibid 74.
 Sheldon (n 18) 7.
 Ibid 4.
 Judith Thomson, ‘A defence of Abortion’ (1971) 1 Philosophy & Public Affairs 47, 63-64.
 John Keown, Abortion, Doctors and the Law: Some Aspects of the Legal Regulation of Abortion in England from 1803 to 1982 (Cambridge: CUP, 1988) Ch 5.
 Thomas Loftus Townshend Lewis, ‘The Abortion Act’ (1969) 1 Brit Med J 241, 242.
 Dilys Cossey, Abortion and Conscientious Objection (London: Birth Control Trust, 1982) 9; Colin. Francome, Abortion Practice in Britain and the United States (London: Allen and Unwin, 1986) 55.
 Sally MacIntyre, Single and Pregnant (London: Croom Helm, 1979) 75-76.
 David Tunnadine and Roger Green, Unwanted Pregnancy – Accident or Illness? (Oxford: OUP, 1978) 4.
 Sally Sheldon, ‘British Abortion Law: Speaking from the Past to Govern the Future’ (2016) 79 MLR 283, 314.
 Department of Health and Social Care, ‘Abortion Statistics, England and Wales: 2018’ (National Statistics, 2019) 12.
 Sian Beynon-Jones, ‘Expecting Motherhood? Stratifying Reproduction in 21st-century Scottish Abortion Practice’ (2012) 47 Sociology 509.
 Sheldon (n 30) 292.
 Montgomery v Lanarkshire Health Board  UKSC 11.
 Ibid .
 Ibid .
 George’s Healthcare NHS Trust v S  3 WLR 936, 957.
 Ellie Lee, ‘Reinventing abortion as a social problem: “Post abortion syndrome” in the United States and Britain’ in Joel Best (ed.) How claims spread: cross-national diffusion of social problems (Aldine de Gruyter: New York, 2001) 39, 43.
 Parkinson v St James & Seacroft University Hospital NHS Trust  QB 266  (Lady Hale).
 Rosamund Scott, ‘Risks, Reasons and Rights: The European Convention on Human Rights and English Abortion Law’ (2016) 24 Med L Rev 1, 24.
 Joanna Erdman, ‘Access to Information on Safe Abortion: A Harm Reduction and Human Rights Approach’ (2011) 34 Harv J L Gender 413.
 Scott (n 40) 12.
 R v Sarah Louise Catt Sentencing Remarks (17 September 2012) para 15.
 Scott, (n 40) 13.
 Ian Kennedy and Andrew Grubb, Medical Law (Butterworths: London, 3rd edn, 2000) 1420.
 Department of Health and Social Care (n 31).
 Andrew Grubb, ‘The New Law of Abortion: Clarification or Ambiguity?’ (1991) Sep Crim LR 659, 661.
 Scott (n 40) 15.
 British Medical Aassociation, First Trimester Abortion: A Briefing Paper by the BMA’s Medical Ethics Committee (ARM: London, 2007) 4.
 House of Commons Science and Technology Committee, Scientific Developments Relating to the Abortion Act 1967, Vol 1, Twelfth Report of Session 2006–07,35.
 Steel (n 14).
 Keown, (n 24) 137.
 Jasmine Coleman, ‘Clinics granting sex-selection abortions to be investigated by health officials’ The Guardian (23 February 2012).
 Andrew Lansley, ‘Health professionals must not think they know better than the law’ The Telegraph (24 February 2012).
 Harry York, ‘Doctors could be prosecuted for gender-based abortion following British lawyers appeal to European Court of Human Rights’ The Telegraph (18 June 2016).
 R v Smith  1 WLR 1510, 1518 (Scarman LJ).
 Kate Greasley, ‘Is Sex-selective abortion against the law?’ (2016) 36 OJLS 535, 558.
 Britain’s Abortion Law: What it Says and Why (British Pregnancy Advisory Service, May 2013) 5. <http://www.reproductivereview.org/images/uploads/Britains_abortion_law.pdf> accessed 24 May 2014.
 Charles Foster, ‘Abortion on the grounds of gender: Like it or not, the DPP was right’ (Practical Ethics) <http://blog.practicalethics.ox.ac.uk/2013/10/abortion-on-grounds-of-gender-like-it-or-not-the-dpp-was-right/> accessed 11 October 2013.
 Rosamund Scott, ‘Interpreting the disability ground of the abortion Act’ (2005) 64 CLJ 388, 390-391.
 Ibid 391.
 Rosamund Scott, Choosing Between Possible Lives: Law and Ethics of Prenatal and Preimplantation Genetic Diagnosis (Hart Publishing, Oxford and Portland, OR 2007) 128.
 Scott (n 60) 400.
 Rosamund Scott, ‘The Uncertain Scope of Reproductive Autonomy in Preimplantation Genetic Diagnosis and Selective Abortion’ (2005) 13 Med L Rev 291, 324.
 Clare Williams, Priscilla Alderson and Bobbie Farsides, ‘Drawing the Line in Prenatal Screening and Testing: Health Practitioners’ Discussions’ (2002) 4 Health, Risk and Society 61, 66.
 Scott (n 64) 326.
 Sally Sheldon and Stephen Wilkinson, ‘Termination of pregnancy for reason of foetal disability: are there grounds for a special exception in law?’ (2001) 9 Med L Rev 85, 107.
 Ibid 103. See John Harris, ‘Is there a Coherent Social Conception of Disability?’ (2000) 26 J Med E 95, 98.
 Sheldon and Wilkinson (n 67) 103.
 Ibid 107.
 Priscilla Alderson, ‘Prenatal Counselling and Images of Disability’, in D. Dickenson (ed), Ethical Issues in Maternal-Foetal Medicine (Cambridge 2002) 195, 201.
 Scott (n 60) 396-97.
 Rosamund Scott, ‘Prenatal Testing, Reproductive Autonomy, and Disability Interests’ (2005) 14 Camb Q Healthcare E 65, 70.
 James Nelson, ‘The meaning of the act: Reflections on the expressive force of reproductive decision making and policies’ in Parens E, Asch A (eds) Prenatal Testing and Disability Rights (Georgetown University Press 2000) 196, 207.
 R v Catt  EWCA Crim 1187.
 Ronli Sifris, ‘Restrictive Regulation of Abortion and the Right to Health’ (2010) 18 Med L Rev 185.
 Ibid 200.
 Jennifer Barber, William Axinn and Arland Thornton, ‘Unwanted Childbearing and Mother-Child Relationships’ (1999) 40 J Health Soc Behav 231.
 Paul Dagg, ‘The Psychological Sequelae of Therapeutic Abortion Denied and Completed’ (1991) 148 Am J Psychiatry 578.
 Michael Sobol and Kerry Daly, ‘The Adoption Alternative for Pregnant Adolescents: Decision Making, Consequences, and Policy Implications’ (1992) 48 J Soc Issues 143.
 Nancy Russo and Kristin Zierk, ‘Abortion, Childbearing, and Women’s Well-Being’ (1992) 23 Prof Psychol-Res Pr 269.
 Dorothy Sit and others, ‘Psychiatric Outcomes Following Medical and Surgical Abortion’ (2006) 22 Human Reproduction 878.
 Marge Berer, ‘National Laws and Unsafe Abortion: The Parameters of Change’ (2004) 12 Reproductive Health Matters 1, 6.
 Reva Siegel, ‘Reasoning from the Body: A Historical Perspective on Abortion Regulation and Questions of Equal Protection’ (1992) 44 Stan L Rev 261.
 Sifris (n 76) 210.
 David Grimes and others, ‘Unsafe Abortion: The Preventable Pandemic’ (2006) 368 Lancet 1908. <http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673606694816.pdf?id=0e96c9e6421f9512:7a2f0723:123a11c858d:efa1252541835984> accessed 10 September 2009.
 Sheldon (n 30) 315-6.
 Ibid 316.
 Erdman (n 41) 458.
 Sally Sheldon, ‘Abortion in late pregnancy: Legal issues’, in Late Abortion: A review of the evidence’ (2004) Pro Choice Forum 1, 27.
 Sheldon (n 30) 293.
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