What to expect when no one's expecting: America's coming demographic disaster

By Jonathan Last. New York: Encounter Books, 2013.

Reviewed by Petrus Simons PhD

Introduction

The world’s population has increased from 3 billion in 1960 to 7 billion by the end of 2011, with 9 or 10 billion expected by 2050. Given that about 1 billion suffer hunger or malnutrition, many believe that the world is over-populated. In contrast, Jonathan Last argues that we should rather worry about a declining birth rate, which in due course will result in a decreasing world population. The populations of Russia, Italy, Japan and Latvia are already declining.

The statistic used is the total fertility rate, defined as the number of live births that women will have during their life, assuming they experience the age-specific fertility rates of a given period. At a rate of 2.1 a population will replace itself. At a lower rate, it will contract. In 1979 the world’s fertility rate was 6.0. It is now 2.52, close to replacement. New Zealand’s rate is around 2.0.

This review will summarise Last’s arguments and then discuss their strengths and weaknesses.

Reasons for falling fertility

Last is concerned with trends and cautions against possible biases such as racism or criticising women for not producing more babies. His reasons for the declining trend can be summed up as follows.

Religion and Secularisation: The waning of the Christian religion, which has always emphasised the blessing of children, has led not only to falling birth rates, but also to easier divorce, higher rates of divorce, declining numbers of marriages, greater acceptance of homo-sexuality and an increase in abortions.

Secularisation is associated with a belief that individuals are autonomous and should decide for themselves how they live. As a result the value of ‘community’ has been declining.

Medical: Better health care has led to a decline in infant mortality and, consequently, has eliminated the need to replace those dying in infancy. Progress in medical technology has also brought new methods of birth control. Sadly, it has also facilitated abortions. Since the US Supreme Court legalised abortion in 1973 (Roe vs Wade), there have been 49.5 million abortions. Currently, in Russia 13 abortions are performed for every 10 live-births. Last notes that “this might be the most grisly statistic the world has ever seen. It suggests a society that no longer has the will to live.” (p.137)

Modern culture: Women, particularly those who are more highly educated and are pursuing a career or trying to earn extra income, have less time to nurture families. Unemployment, lower incomes for many, rising costs of transport and housing, urbanisation and smaller houses, and high costs of child care (including baby car seats, prams etc) are all conspiring to reduce the birth rate. In addition, the availability of social welfare schemes, especially superannuation, has lessened the need to have children who can look after elderly parents.   

A historic shift: Historically, elites have had higher numbers of children than the poor. In Europe this began to change with the advent of the Industrial Revolution at the end of the 18th century. Since then the rich have been reducing the number of their offspring more severely than the poor. This reversal has been repeated just about everywhere. The lower classes follow by having fewer babies as well, so that they too can climb the social ladder. In other words, “reproduction has become an impediment to material success.” (p.74) In the United States, more college graduates with higher mobility means that people are congregating together with those who share their interests and values. As a result, “changes in fertility have altered the fundamental dynamics of American politics.” (p. 130)

Problems

The shift from growing to eventually declining populations entails a variety of problems.

Youth bulges:In some countries births have fallen so suddenly that there exists a bulge of young people. Had the decline happened more gradually, there would have been a number of generations with above-replacement, albeit decreasing, levels of births. Iran is a recent example. It has a ‘surplus’ of young men, who compete for jobs and who might easily be recruited for revolutionary campaigns.

One child policy: In China, the one-child policy that was initiated in the 1980s could lead to shortages of labour as well as pension problems after 2050. Since the policy has encouraged abortions, especially of girls, there is a growing oversupply of young men.

Japan:Japan is probably the country with the most drastic fall in live births since it became the first country to legalise abortion under its “Eugenic Protection Law” after the Second World War. It has also witnessed a decline in marriage and a consequent fall in births. Marriages also end much more frequently in divorce. By 2100, if the present fertility rate continues, the population could fall from 127 million to 91 million.

Redundant infrastructure and economic costs:In Germany, empty houses and shops are making way for parks. Obstetric clinics are turned into nursing homes. In North Rhine-Westphalia the government has retrained prostitutes to become elder-care nurses. In Japan, a depopulated village was turned into a landfill.    

In general, Last identifies the following effects:

  1. A sharp rise in the costs of health care.
  2. Smaller groups of younger people to bear the costs of old age (pensions and health).
  3. A slower pace of human progress due to a declining level of entrepreneurship and inventiveness. (Older people are more risk averse and lack the vigour to invent new things.)
  4. Older societies are less prepared to engage in war or to accept casualties.

Second demographic transition

Not everybody is convinced that falling fertility is a problem.  Demographers Ron Lesthaeghe and Dirk J. van de Kaa believe that low fertility is the result of modernity itself, another stage in our evolution and, therefore, a good thing. They refer to current developments as the second demographic transition, as the first one occurred at the end of the 18th century when the rate of mortality began to decline. Such a transition is complete when the fertility rate reaches the replacement rate. The US and Europe reached this point around 1960. The rest of the world is still in the process of this transition. With fewer children being born, they become very precious, with parents spending more time and effort on them.

What can be done?

Last does not subscribe to the theory that we should not worry about falling fertility. He believes that the trend can be reversed, although not by policies of providing financial incentives and propaganda, which seldom work. So, what does he suggest?

Last’s recommendations are based on three empirically based premises:

  1. Countries do not return to replacement level once their total fertility rate has fallen below 1.5.
  2. Any efforts to stoke fertility must be sustained over several generational cohorts i.e. a decades-long commitment to family growth.
  3. People cannot be bribed into having babies.

Last favours policies that help people have the children they do want. He advocates that the US should reduce the social security tax for those who become parents. He also argues that the costs of sending children to university are far too high and that reform in this area is desirable. Telecommuting might enable families to live near existing social and family networks.

Finally he quotes from Pope Benedict XVI: “Children, our future, are perceived as a threat to the present, as if they were taking something away from our lives. Children are seen as a liability rather than as a source of hope.” (p.175) Importantly, he concludes, Government should welcome believers rather than being hostile to them.

Analysis and Conclusion:

Last provides an admirable review of a world-wide trend of falling fertility, with a comprehensive account of its causes and possible consequences. I believe he is right in emphasising that societies with shrinking populations are less dynamic, and, therefore, face a shrinking tax base, insufficient to meet the demands of both the elderly and the young. Some of these effects are already apparent in countries that have been experiencing declining populations.

It is sobering to note the decline of the Judeo-Christian religion in our modern world as a key factor. In this respect, his account of a reversal of the falling trend in Georgia, in response to a call by the Orthodox Patriarch, is encouraging.  

Last does not address the problem of an increasing number of men suffering from a low sperm count. Although it is possible to overcome this to an extent by IVF, it contributes nevertheless to falling fertility.  

His view that the trend towards falling populations will have dire consequences for the welfare state is much exaggerated. Higher expenditures on the elderly due to an ageing population will be offset by lower expenditures on the young. Since the trend is long-term, policies can easily be adjusted.

Last does not discuss whether the world is able to care adequately for a population of, say, around 9/10 billion, assuming that it would stabilise at this level. Would there be sufficient clean water, proper food and clear air for all?

I would argue that the current ideology of exponential economic growth based upon science and technology stands in the way. Our technical-economic system destroys and pollutes fertile land, warms the climate, produces food that is less and less nutritious, creates stressful jobs and makes many people unemployed. The baby-robots made in Japan to get women interested in real babies symbolise our technologised civilisation. Is our culture committing suicide?  

Yet, change is possible as shown by Georgia’s Patriarch Ilia II’s actions to reverse a fertility collapse. His “mass baptisms are now a staple of Georgian life.” (159) It is a country in which the Christian religion still holds an important place.    

Last has issued a warning that the trend of falling fertility is not a healthy one. His warning is addressed especially to the United States. This may explain why his style is rather colloquial. Had he generalised his story he could have dealt an even greater blow to the myth of the world becoming over-populated.   

Dr Petrus Simons is a retired economist with a PhD in philosophy. He is a contributor to the South African journal "Koers".

 

 

 

Responding to loss in pregnancy

 

Meredith Secomb

Introduction

Every one grieves the death of an infant. Parents who have tragically lost their baby to cot death or illness find that others grieve with them. Immediate family and extended family, friends and acquaintances all recognise the heartbreaking nature of what has occurred. There are funeral rites which aid the grieving process; there are photographs to reflect upon. Even the sad, sad task of packing up baby clothes is a means of coming to terms with the reality of the distressing loss. In contrast, the experience of those who suffer loss during pregnancy can be very different. In this paper I want to reflect on the grief occasioned by the loss of a baby to miscarriage, stillbirth or abortion and suggest ways in which we might respond with heightened awareness and compassion to them.

Some general comments on grief and loss

After the publication in 1970 of the ground-breaking work of Elisabeth Kübler-Ross, On Death and Dying, her five stages of grief entered into the lay-psyche.[1] We read that grieving people regularly go through a stage of denial. The painful truth is often too much to handle in the immediate after-math of learning of a present or potential loss. This can be a constructive coping strategy in the short-term and it requires that the support person respects the need to process the news at a rate that is manageable. Similarly, we need to appreciate that people often become angry at their circumstance, displacing it onto immediate others, the medical establishment or God. Anger is another means of dealing with pain, distancing the sufferer from the interior grief that is too much to handle. Bargaining and a period of depression may follow but, if support has been adequate and patients have been allowed to process their feelings and thoughts in the context of compassionate others, eventually there may occur the healing process of acceptance. Ultimately, our understanding of Kübler-Ross’ work was more nuanced and we came to realise that these stages were not linear, for people may well revisit a stage that they had previously encountered.

These observations have certainly been helpful insofar as they have enabled us to respect the range of emotions which grieving people may experience. More recently, however, the process of grief that Kübler-Ross articulated has been questioned. George Bonanno’s evidence-based research challenges the notion that there are differentiated stages of grief. Instead Bonanno identified three common patterns of grief reaction: people who manifested resilience, people who demonstrated a recovery pattern, and people who suffered chronic grief. [2] Those in the resilient category struggle with emotional pain that is often acute but they are able to meet the everyday demands of their lives, putting the grief aside when required. Those in the recovery pattern find that grief seriously impinges on their present quality of life but they are nevertheless moving towards their pre-grief state. The remainder experience prolonged grief that is enduring and extreme, frequently requiring the help of mental health professionals.

It is this latter group with which I am primarily concerned in this paper. Societal as well as personal factors contribute to the depth of suffering experienced by these women and, frequently, by their partners. It is my hope that a presentation of these factors will help us in our compassion and support for those whose loss, whether acknowledged or unacknowledged, conscious or unconscious, dominates their lives and frequently impacts the lives of those around them.

The grief of miscarriage and stillbirth

In Australia the loss of a baby before the first twenty weeks is called a miscarriage; after twenty weeks the loss is a stillbirth. The grief occasioned by a miscarriage for both the woman and her partner is often underestimated with both anxiety and depressionbeing possible consequences of the distress following miscarriage.[3] A stillbirth is even more devastating; the intensity of grief has been found to be greater when gestational age is longer.[4] Parents are seldom prepared for the possibility of the loss of their baby in antenatal classes, intended as they are to provide support for a healthy live birth. Baby magazines do not engage with it; friends do not know how to react. The woman and her partner are often left alone to deal with the pain of loss, unaware that there are many other like sufferers.

In fact pregnancy loss is quite common with twenty-five percent of women experiencing a loss of some kind during their pregnancy and one percent of couples suffering recurrent losses.[5] Nevertheless, the woman often encounters emotional isolation as she struggles to come to terms with her grief, often feeling that even her partner does not understand her experience. The agonising search for an answer to the question “Why?” can be compounded by feelings of failure and frustration, and sometimes by guilt and shame, particularly for those with repeated losses. Both miscarriage and stillbirth generate a unique set of complex emotions which insensitive responses from family, friends and professionals can exacerbate. For example, a well-meaning comment of “You’ll get pregnant again” or “It was only a miscarriage” or “It was probably for the best” will just increase the grieving mother’s disappointment and sense of isolation.

Parents need to find ways to manage their grief, grief that can seem to tear them apart. These ways vary according to the circumstances and unique needs of the mother or couple. Frequently women who have had a miscarriage need to recognise that they have a right to grieve even if their loss seems considerably less than that of others who have, for example, lost a child at birth or in infancy. Karen Edmiston poignantly conveys the reality of such grief: “When does life begin? Conception. When does life begin to be important, memorable, meaningful, sacred, worth grieving over? Conception.”[6]

Women grieving the loss of their baby need to accept that little, often unidentifiable, things can trigger a recurrence of grief. They need also to find ways of coping with their grief. Strategies for coping with loss to miscarriage can be many and varied. Some mothers use online resources, blogging or creating an online memorial; others will decorate the Christmas tree with the child’s memory in mind. The family may acknowledge their dead child in the “count” of their children.[7] There are many other means of acknowledging the reality of the deceased child’s life.[8] Appropriate professional intervention can also make a significant difference. There is evidence that supportive hospital care can aid both physical and emotional recovery following a miscarriage.[9]

In giving birth to a stillborn child the mother is confronted with extremely complex emotions. Life and death converge.[10] There has been a birth but there is silence; instead of welcoming their child into the world the mother and father must farewell their baby. One woman observed, “I am angry, unbelievably sad. I feel lonely, lost and beg to wake up from this nightmare. My whole being has been ripped to shreds.”[11] Many mothers understandably report feelings of emptiness that touch them both emotionally and somatically.[12] Subsequent pregnancies are likely to generate much anxiety with the fear that failure may attend this pregnancy also. Mothers who have miscarried often lament that there is no body to hold and ultimately to bury. Those who have a stillborn child do have that option and many claim it is a help in their grieving process.[13]  

Whether the loss in pregnancy is due to miscarriage or to stillbirth, enormous sensitivity and compassion is needed to convey a felt sense of support to the grieving mother and her partner. The grief of loss due to miscarriage and stillbirth generates a range of distressing emotions.[14] However, the grief associated with an induced abortion is even more distressing because it has often to be hidden due to fear of societal judgement. Abortion can generate a complicated grief that impinges upon lives with disturbing and long-term consequences.

The grief of abortion

A preliminary reflection

The evidence regarding the psychological or mental health risks associated with an abortion supports the positions of neither the pro-life nor the pro-choice movements.[15] A study of 500 women to the age of thirty revealed that the majority of respondents reported that they had made the “right decision” in having an abortion.[16] The researchers comment that these findings call into question “strong pro-life positions that depict unwanted pregnancy terminated by abortion as consistently having devastating consequences for women’s mental health.”[17] On the other hand the results do not support the pro-choice movement either insofar as the movement argues that abortion is without any deleterious mental health consequences.[18] Certainly there is no evidence to substantiate the notion that abortion reduces the mental health risks associated with an unwanted and continuing pregnancy.[19]

Instead, it is claimed that there is justification for holding a “middle-of-the-road position” wherein  mental health problems do arise for those women who experience abortion as a “stressful and traumatic life event.”[20] Coleman goes further in insisting that “abortion is associated with moderate to highly increased risks of psychological problems subsequent to the procedure.”[21] Moreover, for those women with a prior history of abortion there is evidence that mood disorders and substance abuse significantly increase.[22] It is with those for whom abortion and its sequelae are traumatic and enduring that I am concerned.

The complicated grief of abortion

A range of circumstances may trigger the perceived need for an abortion. The woman approaching menopause may feel she simply cannot “do babies” again. The woman may suffer a disability. There may be migrant and cross-cultural problems that militate against a woman being pregnant outside marriage. The major group, however, that presents for abortion is the 15-25 year age group.

The grief of abortion is complicated. The woman who has had an abortion is meant to be relieved that her “difficulty” has been resolved. She is not expected to grieve. Indeed, neither she nor her partner feel they have permission to grieve.[23] Grief may not surface until many years later. The impact of the abortion may only be revealed, for example, in the context of psychological help for difficulties in relating to her marriage partner. Or the repressed trauma of an abortion may trigger painful somatic memories, the meaning of which is only discovered with therapeutic support.[24] Karol Woytyla observed that abortion may cause “an anxiety neurosis with guilt feelings at its core, and sometimes even a profound psychotic reaction” and that sometimes decades later a depressed woman may “remember the terminated pregnancy with regret and feel a belated sense of guilt.”[25]

 In the immediate aftermath of an abortion it can be a shocking surprise to a woman when she finds herself grieving her lost child with no tangible means of remembering her baby. In this respect the grief of abortion can be similar to miscarriage. There are, however, additional factors that confound the grieving process.

Often significant others have exerted pressure upon her to have an abortion, with self-interest either consciously or unconsciously in mind: her partner, her parents, friends, the dearth of adequate counselling support at an abortion clinic.[26] Abortion is usually offered to a woman as a quick solution that can resolve the many social, economic and, for younger women, educational problems confronting her. Hence the choice to abort is typically a forced choice. These pressures and the ensuing shame and guilt create the circumstances for much more mental disturbance than that occasioned by miscarriage or stillbirth. The stress subsequent to abortion has been seen as so extreme that the notion of a “post-abortion syndrome” has been proposed.[27]

The literature presents a range of debilitating psychological problems that a woman may suffer subsequent to abortion: low self-esteem, guilt, depression, suicidal thoughts, broken relationships, nightmares, flashbacks, anger, drug and alcohol use, sexual promiscuity and dysfunction, phobias and compulsive disorders. She may also find an inability to express emotions and discover that events that remind her of her dead baby hinder her engagement with age-appropriate activities. So, for example, she may be unable to attend a friend’s baby shower, or rejoice in a friend’s pregnancy. Her interaction with children can become unhealthy, either fearing or abusing them.[28]

Abortion affects not just the woman. Men, too, can be affected by abortion. They can feel powerless and angry if the decision to abort was made independent of them. On the other hand, if they pressured the woman to abort, guilt and sorrow may surface months or years later. Families and siblings of the dead child are also affected. A child who has been told that “if the baby is not all right the doctor is going to send the baby back to God,” may worry that he or she also is not “all right.”[29] Such anxiety generates significant existential insecurity with behavioural consequences for the child.

Those who suffer the grief of abortion, whether the woman, her partner or others affected by the abortion, need understanding and compassion. They also need hope.[30] I turn now to consider the ways in which sufferers of loss in pregnancy can be supported.

Care for those suffering loss in pregnancy

Pope Benedict XVI called for an “attitude of merciful love” to those suffering the effects of abortion and divorce.[31] And, indeed, there is an increasing awareness of the need to support those suffering grief following a loss in pregnancy.

Women do ring up various agencies looking for support after an abortion. It is very important to receive them in a non-judgemental manner, respecting the person and conveying understanding and compassion.[32] In the case of an abortion, such a response does not negate the seriousness of what has occurred.[33] It does, however, demonstrate that the value and dignity of the person has primacy in the eyes of the support person. Empathic support will enable a woman to do the necessary work of grieving, which is a first and essential part of the journey towards healing.

Whether it is a miscarriage, stillbirth or abortion that is the issue, there is a particular type of listening that provides a healing space in which the person, woman or man, feels safe and hence able to open up to the painful depths within, as well as open out to the listening person. It is the empathic, reflective listening that occurs when the support person is fully present in spirit to the suffering individual. Such listening is fully engaged; the woman knows she has the full attention of the listener. Moments of silence are valued and not hurried over. Periods of crying are quietly accepted. The full range of emotions must be recognised as a normal part of the grieving process:

The dreadful despair must be accepted as such and must be regarded as appropriate to this particular life situation. In addition, the chaotic emotions, especially the anger, must be endured. This is made easier by an understanding that the emotional chaos represents the dismantling of the old patterns of relationship and the old habits and therefore also the creation of a new potential.[34]

In helping people recognise, acknowledge and accept their grief, the counselor is also helping to effect transformation of the personality. The way is being created for old habits of emoting and thinking to be replaced by new, more constructive ones. For this to happen it is essential that the grieving process is given expression.

For those suffering the grief of an abortion the work done by the Project Rachel Ministry is particularly helpful.[35] In the context of a retreat for those who have had an abortion, spiritual ministry reaches deep into the wounded spirit of those who have felt condemnatory judgement from themselves, the church or the community. Again, listening and acknowledgement of the woman’s pain must be given priority as instanced by the following observation:

I have found that time taken to listen to the story in some detail is all that’s needed to help make the connection. Many people may have listened to the story – although usually it is only a few – but when the person is listened to by the priest something happens to connect the person with God, forgiveness and their need for spiritual healing. While God’s healing is not dependent on a priest, it is clearly important for some to hear the priest acknowledge the pain they suffer for this spiritual healing to take place. This is especially true for those who have felt rejected by a priest or the church.[36]

Towards hope: an existential reflection

One of the consequences of an abortion, or indeed of any form of pregnancy loss, can be an identity crisis.[37]People who have been subjected to extreme suffering frequently find that their usual modes of self-experience and of relating to the world have been stripped away.[38] They experience agitation and restlessness. They speak of feeling “lost” and of being separated from others in ways that are distressing to them. Their suffering challenges their previous felt-sense of presence to themselves. It also challenges their relationship with God who often appears painfully absent. They have been stripped of their previous roles and personas. Their self-concepts have changed and they have no new concepts with which to replace them. They are no longer able to make sense of who they are. Emotionally, socially, cognitionally, somatically and spiritually they are in new and unfamiliar territory.  They are exposed to a mysterious and disturbing void at the core of their being and a profound existential self-question arises from that experience, the question “Who am I?” Learning to accept their emptiness with equanimity can be foundational for significant transformational change.

By attending to the experience of emptiness, and to the existential question that subsequently arises, people can be led to a vocational exploration, answering the question of “Who am I?” with the discovery of what God is calling them to do.[39] Indeed, as Pope Benedict XVI has observed, in affirming the dignity of the human person and the human person’s capacity to love, “[P]eople are able to respond to the loftiest vocation for which they are created: the vocation to love.”[40] The question for the person on the way towards healing will be the unique form in which that vocation to love will be expressed. It is encouraging for those involved in the work of “healing of souls” that they are also contributing to the salvation of humanity for, as Pope Benedict XVI observed, “without the healing of souls, without the healing of man from within there can be no salvation for humanity.”[41]

Conclusion

Loss of a child in pregnancy, whether due to miscarriage or stillbirth or abortion, is a cause of great grief and suffering. Everyone recognizes that stillbirth is extremely painful, but people often underestimate the extent of the grief also occasioned by miscarriage. Both circumstances require compassion and sensitivity on the part of others. However while miscarriage and stillbirth cause significant grief, they have not been associated with clinically recognised mental disorders to the same degree that abortion has. Whereas the death of a baby in miscarriage and stillbirth happen to a woman, in the case of abortion a woman chooses to have her baby die. However, the choice is a forced choice, a factor which significantly complicates the grieving process. Pressures exerted by her partner, her family, her culture and her psycho-social needs can all combine to create a perceived need to abort. Mental disorders, substance abuse and relational difficulties can then impact on women’s lives for years. Increasingly organizations such as those mentioned above are becoming available to assist women and their partners to acknowledge and work through their grief. As women and men do so, they are afforded the opportunity to find God’s grace in their suffering and to see that God’s love can transform even the darkest experience, giving their lives meaning and purpose.

Meredith Secomb has a PhD in theology from the Australian Catholic University (Melbourne) and has worked as a clinical psychologist in both the public and private sectors, the latter specialising in the interface of psychology and spirituality. This paper was originally delivered in Melbourne at the 2013 National Colloquium for Catholic Bioethicists which explored the topic “Issues in Mental Health and Drug Addiction.”

  


[1]Elisabeth Kübler-Ross, On Death and Dying (London: Tavistock Publications, 1970).
[2] See especially George Bonanno, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss (New York, NY: Basic Books, 2009), 6-7.
[3] See Philip M. Boyce, John T. Condon, and David A.  Ellwood, "Pregnancy Loss: A major life event affecting emotional health and well-being," Medical Journal of Australia 176, no. 6 (2002): 250-251; K. Conway and G. Russell, "Couples' Grief and Experience of Support in the Aftermath of Miscarriage," British Journal of Medical Psychology 73, no. 4 (2000): 531-545; Pamela A. Geller, Danielle Kerns, and Claudia M. Klier, "Anxiety following Miscarriage and the Subsequent Pregnancy: A Review of the Literature and Future Directions," Journal of Psychosomatic Research 56, no. 1 (2004): 35-45; Ingrid H. Lok and Richard Neugebauer, "Psychological morbidity following miscarriage," Best practice & research. Clinical obstetrics & gynaecology 21, no. 2 (2007): 229-247; Richard Neugebauer and others, "Depressive Symptoms in Women in the Six Months after Miscarriage," American Journal of Obstetrics and Gynecology 166, no. 1 (1992): 104-109.
[4]M. C. J. Cuisinier and others, "Miscarriage and Stillbirth: Time Since the Loss, Grief Intensity and Satisfaction with Care," European Journal of Obstetrics & Gynecology and Reproductive Biology 52, no. 3 (1993): 163.
[5]Zoe Taylor, "Pregnancy Loss: Surviving Miscarriage and Stillbirth," (2010). http://www.amazon.com/Pregnancy-Loss-Miscarriage-Stillbirth-ebook/dp/B003CQIB0A/ref=sr_1_1?ie=UTF8&qid=1354408593&sr=8-1&keywords=Zoe+Taylor (accessed December, 2012), loc. 73.
[6]Karen  Edmisten, After Miscarriage: A Catholic Woman's Companion to Healing and Hope (Cincinati, OH: Servant Books, 2012), 6.
[7] See Edmisten, After Miscarriage: A Catholic Woman's Companion to Healing and Hope, 6; Taylor, Pregnancy Loss: Surviving Miscarriage and Stillbirth, loc. 326.
[8]Taylor, Pregnancy Loss: Surviving Miscarriage and Stillbirth, loc. 326.
[9]K. Stratton and L. Lloyd, "Hospital-based Interventions at and following Miscarriage: Literature to Inform a Research-practice Initiative," Australian and New Zealand Journal of Obstetrics and Gynaecology 48, (2008): 5.
[10]Joanne Cacciatore, "Psychological Effects of Stillbirth", Elsevier http://www.sfnmjournal.com/article/S1744-165X(12)00102-3/abstract.
[11]Taylor, Pregnancy Loss: Surviving Miscarriage and Stillbirth, loc. 2383.
[12]Sherokee Ilse, Empty Arms: Coping with Miscarriage, Stillbirth and Infant Death (Maple Plain, MN: Wintergreen Press, 2008).
[13]Badenhorst and Hughes observe that there is no evidence-based data for such a practice and that it “may have adverse effects, including symptoms of post-traumatic stress disorder,” for which see William Badenhorst and Patricia Hughes, "Psychological Aspects of Perinatal Loss," Best Practice & Research: Clinical Obstetrics & Gynaecology 21, no. 2 (2007): 249.Further studies are needed in this regard.
[14]Note, however, that there is no evidence to indicate that such distress is clinically significant. For the observation that there is no consistent association between pregnancy outcomes, other than abortion, and mental health, see David M. Fergusson, L. John Horwood, and Joseph M Boden, "Abortion and Mental Health Disorders: evidence from a 30-year longitudinal study," The British Journal of Psychiatry 193, (2008): 448.
[15] Implicit in this dichotomy is a failure to recognise the movements which adopt neither position, but rather uphold the rights and values of both the woman and her child, for which see “Feminists for Life” (feministsforlife.org) who argue that women should not have to make a choice between their place in society and their unborn children. Feminists for Life argue that as a society we need to address the lack of psycho-social, economic and spiritual resources that prevent women bringing their children to term.
[16]David M. Fergusson, L. John Horwood, and Joseph M. Boden, "Reactions to abortion and subsequent mental health," British Journal of Psychiatry 195, (2009): 425.
[17]Fergusson, Horwood, and Boden, "Reactions to abortion and subsequent mental health," 425.
[18]Fergusson, Horwood, and Boden, "Abortion and Mental Health Disorders," 450.
[19]Priscilla K. Coleman, "Abortion and Mental Health: quantitative synthesis and analysis of research published 1995-2009," British Journal of Psychiatry 199, (2011): 185.
[20]Fergusson, Horwood, and Boden, "Abortion and Mental Health Disorders," 450.
[21]Coleman, "Abortion and Mental Health," 183.
[22]N.P. Mota, M. Burnett, and J. Sareen, "Associations between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample," Canadian Journal of Psychiatry 55, no. 4 (2010): 239-247.
[23]E. Joanne Angelo, "The Psychological Aftermath of Abortion for Children and Families: A Clinical Perspective," in Oil on the Wounds: A Contemporary Examination of the Effects of Divorce and Abortion on Children and their Families ed. Livio  Melina and Carl A. Anderson(Garden City Park, NY: Square One Publishers, 2011), 193-194.
[24] See Babette Rothschild, The Body Remembers (New York: W. W. Norton & Company, 2000).
[25]Karol Wojtyla, Love and Responsibility (San Francisco, CA: Ignatius Press, 1993), 285.
[26]For an excellent presentation of the range of factors confronted by a woman who has experienced abortion, including comments on the poverty of pre-abortion counselling, see Melinda Tankard Reist, Giving Sorrow Words: Women's Stories of Grief after Abortion (Sydney: Duffy and Snellgrove, 2000), 12-43.
[27] See John J. Dillon, A Path to Hope: For Parents of Aborted Children and Those who Minister to Them ( Williston Park, NY: Resurrection Press, 1990), 20-33; Vincent M. Rue, "The Psychological Realities of Induced Abortion," in Post-Abortion Aftermath, ed. Michael T. Mannion(Kansas City, MO: Sheed and Ward, 1994), 5-43. Note, however, that the current Diagnostic and Statistical Manual of Mental Disorders has not adopted this proposal and does not cite psychological consequences of abortion as a recognized syndrome, for which see American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth ed. (Washington, DC: American Psychiatric Association, 1994). Certainly the stresses occasioned by abortion constitute an adjustment disorder with anxiety and depression being concomitant symptoms.
[28]See Dillon, A Path to Hope, 20-30.
[29]Angelo, "The Psychological Aftermath of Abortion for Children and Families," 195.
[30] See David C. Reardon, ed. Hope and Healing (Springfield, IL: Elliot Institute, 1998), 11.
[31]His Holiness Benedict XVI, "Address to the Participants at the International Congress," in Oil on the Wounds: A Contemporary Examination of the Effects of Divorce and Abortion on Children and their Families, ed. Livio Melina and Carl A.  Anderson(Garden City Park, NY: 2011), xi.
[32] Note the unfortunate experience of Jilly Smith who, on first seeking support, was told that she needed to ask God’s forgiveness for her sin of abortion. This was a response that totally alienated her from the Christian agency, for which see Jilly Smith, "How to Feel Better after an Abortion: A Neutral Guide to Recovery," (Amazon Digital Services, 2012). http://www.amazon.com/Feel-Better-After-Abortion-ebook/dp/B00846MZJG/ref=sr_1_1?ie=UTF8&qid=1357366271&sr=8-1&keywords=Jilly+smith (accessed December 2012).
[33] For Pope John XXIII’s observation that we must “distinguish between error as such and the person who falls into error,” see Jean Laffitte, "To Act According to the Merciful Example of God," in Oil on the Wounds: A Contemporary Examination of the Effects of Divorce and Abortion on Children and their Families ed. Livio Melina and Carl A. Anderson(Garden City Park, NY: Square One Publishers, 2011), 214.
[34]V. Kast, A Time to Mourn: Going through the Grief Process, trans. D. Dachler and F.  Cairns (Einsiedeln, Switzerland: Daimon Verlag, 1988), 53-67.Emphasis added.
[35]US Catholic Bishops, Project Rachel Ministry: A Post-Abortion Resource Manual for Priests and Project Rachel Leaders (Washington, DC: United States Conference of Catholic Bishops, 1999). See also Vicki Thorn, "Project Rachel: A Sacramental Response to the Grief of Abortion," in Oil on the Wounds: A Contemporary Examination of the Effects of Divorce and Abortion on Children and their Families ed. Livio Melina and Carl A. Anderson(Garden City Park, NY: Squarae One Publishers, 2011), 219-230.
[36]Fr Peter Maher, http://www.rachelsvineyard.org.au/, Accessed Dec 12, 2012.
[37]Michael T. Mannion, ed. Post-Abortion Aftermath (Kansas City, MO: Sheed and Ward, 1994), 3.
[38] The following account derives from my own experience of working at the interface of psychology and spirituality.
[39] For an extended discussion of this issue see Meredith Secomb, “Hearing the Call of God: Toward a Theological Phenomenology of Vocation” (PhD dissertation, Australian Catholic University, 2010).
[40]Benedict XVI, "Address to the Participants at the International Congress," xiii.
[41] Pope Benedict XVI cited in Bishops, Project Rachel Ministry: A Post-Abortion Resource Manual for Priests and Project Rachel Leaders, viii.

Intensive care: because you’re worth it?

Consultant in Paediatric Palliative Medicine Richard Hain explores the question: "Are there children for whom intensive care and resuscitation are not appropriate?" Beginning with the notion that a "sense of moral discomfort is surely not a robust enough base on which to build a sound ethical approach," Hain argues that agreement about the need to withhold or withdraw treatment can potentially mask serious differences about the value of children with life-limiting conditions.

Available online at: http://www.thinkingfaith.org/articles/20121211_1.pdf

The dubious ethics of creating children with three genetic parents

Margaret Somerville discusses ethical issues concerning the creation of a child with three genetic parents. She describes such a procedure as altering the human germline, and discusses the ramifications of this in terms of international legal and ethical positions that have been held up to now.

This article is available online here: http://www.mercatornet.com/articles/view/the_dubious_ethics_of_creating_children_with_three_genetic_parents

“Going Dutch”: Euthanasia and the Beautiful Game

John Kleinsman

My accent is Kiwi but the name gives it away. I'm a first generation New Zealander of Dutch descent and it is something I'm proud of. I'm also a football fan – I love watching 'the beautiful game' and once enjoyed playing it!

The Dutch are known for many things including the quality and technique of their football. It was the Dutch who, in the 1970's, invented what is now known as 'total football', a tactical style in which players' positions are interchangeable as part of a general method of attack – difficult to defend against. It's very much a team oriented approach and around the world football coaches have learnt much from this Dutch innovation.

Ironically, while they have over the years continued to produce players of exquisite talent and ability who perform exceptionally as individuals, the Dutch football teams have also gathered a reputation for self-destructing at the highest level of competition and they now carry the tag of being the best team never to win the World Cup; three finals and three defeats! Commentators agree that this is largely the result of internal divisions brought on by the inability of their talented and strong (some would say stubborn) individuals to create a team culture; total football on the field is not compatible with an individualistic approach off it.

The Dutch are also well known for being the first country in the world to legalise euthanasia; something that evolved from turning a blind eye to euthanasia to openly tolerating its practice and eventually to legalising it in 2002. It has occurred to me that there is a commonality between this fact and their struggles on the football pitch.

I have always been intrigued by the fact that the debate about euthanasia (and physician assisted suicide) is prominent only in certain societies, namely affluent white western societies. Why is that? It's a question that is rarely explored. My own hunch is that it is a feature of those largely secular societies where certain assumptions prevail; where the dominant notion of personhood is individualistic and the dominant 'virtue' is the individual's right to make his or her own choices. This emphasis on autonomy and rights shapes us to see the world as belonging to those who are independent, strong and productive. It also shapes us to see moral issues and dilemmas in a certain and very narrow way.

The liberal case in favour of euthanasia is not without its own logic. The argument is made by proponents of change that legalising euthanasia will not adversely affect the freedom of those who do not want to die in this way. On the other hand, the ongoing prohibition of euthanasia unfairly prevents some (albeit a very small minority) from exercising their freedom of choice; the personal beliefs of one group are then effectively being forced onto others, or so the argument goes. In this way, those in favour of euthanasia frame the issue in terms of the protection of rights; specifically the right to choose. The current law in New Zealand is seen as bad law because it unfairly prevents people from making their own end-of-life decisions. Good law, it is stated, upholds individual choice above all.

At this point in the debate I suddenly find myself agreeing with those proposing a change in the euthanasia laws. And I say to them: 'You are right. This debate is about choice!' They look surprised and quizzical while I continue: 'What you don't realise is that it is the legalisation of euthanasia that will ultimately take away people's choice.'

A law change that allowed for people in certain circumstances to dispose of themselves (physician assisted suicide) or be legally 'disposed of' would inevitably start to reshape the way we looked at sickness, old age, disability and death. In particular there would exist the temptation for relatives, as well as over stretched and under resourced care institutions, to see those who are disabled and sick as a burden to be shed rather than as persons to be cared for. Furthermore, and perhaps even more seriously, legalising euthanasia has the real potential to change the way in which those who are disabled, sick and elderly see themselves. These people are already vulnerable because of disability, sickness or infirmity. In a world in which they feel undervalued and isolated they will more easily come to see themselves as a burden and will want to do the right thing if euthanasia is legalised. The so called 'right to die' all too easily becomes a 'duty to die'. On-going debates about the costs of caring for people in the last six months of life fuelled by greater pressure on health-care resources and growing numbers of elderly persons living in institutions will only further exacerbate this pressure.

In other words, the net result of legalising euthanasia would be that those who are most vulnerable will become subject to various forms of physical and psychological coercion. Upholding the choice of a few to be euthanised will effectively take away the choice of large numbers of others to live. What is initially presented as a matter of freedom and choice now comes to look more and more like the imposition of a burden. In the words of one who knows and for whom the desire to live is at times already tenuous in the face of the burden his chronic illness places on others: "If euthanasia were a legitimate option ... then life for the chronically seriously ill would become contingent upon maintaining a desire to continue in the face of being classified as a burden to others ... The mere existence of the [euthanasia] option will affect attitudes to our care, and hence our own willingness to continue."

Furthermore, it is both impossible and contrary to reason to limit euthanasia to a particular group of persons, such as adults or those with a physical terminal illness. Recent developments in Belgium, Holland's closest neighbours, which have extended euthanasia to children, are the most recent testament to this. In the words of one commentator: "The right approach to life and death cannot be restricted to adults. It stands to reason that if euthanasia is a virtuous and compassionate act and a right given by law, then restricting it to only the aged and excluding children is illogical." If euthanasia is permitted as a 'treatment' for pain and suffering then it has to be made accessible to all people.

That inevitably includes people incapable of making a competent choice? While the Belgian law regarding children stresses that the child must repeatedly request euthanasia and be proven to have the capacity to understand what they are asking for, it is, ultimately, just as illogical to restrict euthanasia to those who are competent. No other medical treatments are given or withheld on the basis of a person's competence.

The experiences of the Dutch are, once again, instructive in this regard. Euthanasia of neonates has long been tolerated under what is known as the Groningen Protocol. More recently a public referendum has been initiated in the Netherlands that would allow those over 70 to access euthanasia for no other reason than that they were 'fed up' with life. This would include people who felt isolated, who were demoralised or who felt themselves to be of no use and a burden. As one commentator notes: "Euthanasia in the Netherlands has gone from requiring terminal illness to no physical illness at all, from physical suffering to depression only, from conscious patients to unconscious, from those who can consent to those who cannot, and from being a measure of last resort to one of early intervention."

Thus, legalising voluntary euthanasia is tantamount to permitting all forms of euthanasia – voluntary and non-voluntary and, as international evidence shows, will invariably lead to cases where people are euthanised against their explicit wishes (involuntary euthanasia). It is, therefore, inevitable that choice will be undermined.

To reiterate; the choice to allow euthanasia to remain illegal is a choice in favour of the rights of people rather than the opposite as proponents claim. However, it is now readily apparent that we are talking about a particular kind of choice. It is a choice that recognises the needs of the most vulnerable. It is a choice to promote and uphold the common good. It is a choice that locates individual decisions within a community perspective. It is a choice to care. It is more of a 'total football' approach to life which recognises that strong minded individuals do not always bring back the winners medal.
It is evident to me that Maori and Pacific Island cultural perspectives have been largely absent from New Zealand discussions on attitudes to dying. It is their voices we need to bring a fresh perspective. The Western approach considers respect for human life almost exclusively at the level of respect for the individual while ignoring the effects such a law change would have on society and at the institutional level, in particular its effect on the institutions of law and medicine. It is an approach which too easily neglects the fact that, when all is said and done, we are all interconnected persons whose identity and well-being is tied up with being part of a caring and inclusive community.
'Going Dutch.' In the colloquial sense it's all about individuality; paying one's own way, going it alone, not wanting to be beholden or a burden, being independent. 'Going Dutch?' No thanks.

I will, of course, keep on barracking for the Dutch football team as they travel to Brazil for another go at that elusive World Cup just as I will continue to be vociferous and staunch in my opposition to euthanasia. Come to think of it, I am even grateful to the Dutch for demonstrating so clearly the dangers of euthanasia ... if only they would go back to a 'total football' philosophy.

John Kleinsman is the director of the New Zealand Catholic Bioethics Centre – The Nathaniel Centre

Why euthanasia slippery slopes can’t be prevented

Margaret Somerville logically and articulately argues that when it comes to euthanasia, “logical and practical slippery slopes are unavoidable and inevitable.” The initial “conjunctive justification compromised of respect for individual autonomy and the relief of suffering” is gradually supplanted by an appeal to either justification on its own which opens the way for non-voluntary and involuntary euthanasia.

This article is available online here: http://www.mercatornet.com/careful/view/13676

The sacramentality of adoption: A Trinitarian love

The article by Timothy O’Malley examines the nature of adoption, challenges the stigma associated with it, and suggests that adoption can be viewed as a strongly sacramental icon – an act of self-giving love on the part of the mother that infuses the child’s existence from the very first moment.

This article is available online here: http://americamagazine.org/issue/trinitarian-love

Euthanasia: A child’s choice?

Rev Dr Gerard Aynsley

It is difficult to imagine a more painful reality than that faced by parents of a terminally ill child. Is child euthanasia the answer? In Belgium politicians have voted overwhelmingly ‘yes’.

Chris Cleave, in his 2012 novel, ‘Gold’, takes the reader into the mind of seven-year-old Sophie who is receiving treatment for Leukaemia. The author gives a powerful portrayal of the sort of angst a child may experience when seriously ill and the ways the child will, quite naturally, be concerned for her parents. Sophie is forever attempting to protect her parents from knowing how sick she is, and, in doing so, unwittingly prevents her parents from being involved in her care. I was reminded of the character, Sophie, when reading in Saturday’s Otago Daily Times (15.02.14) that members of the Belgium Parliament had voted 86 to 44 in favour of lifting restrictions to their present Euthanasia law so that terminally ill children could request the assistance of a physician to end their life. The Belgium proposal takes into account that a child’s “legal age isn’t the same as mental age” and that a child can have “a capacity for discernment”. I concur that a child has the capacity to make important choices, but the vulnerability of the child and the possibility that, like Sophie, a child may inadequately understand a situation must be kept in mind.

It was as a member of the Otago Ethics Committee some years ago that I saw some of the practical ways in which a child’s capacity to choose could be honoured. As a committee we held strongly to the view that children should, where possible, be included in the consent process and in discussions about their own health. Inasmuch as it was possible our committee would insist that researchers involve the children in the decision-making and that they explore ways of conveying information that was accessible to the particular age of the child. We also encouraged researchers to have an agreement form for the child to complete additional to the legal consent signed by the child’s parent or guardian. While there was a deep respect for the child’s choosing capacity, forefront in our minds was the fact that children are vulnerable, and a sick child is particularly vulnerable. A child needs others to stand up for them; to ensure there are proper safeguards; to consider the more complex possibilities. The vulnerability of the child needed to be taken into account and the most important way this was addressed was by ensuring the child’s choosing didn’t occur in isolation.

Choosing doesn’t occur in a vacuum, but rather in a complex web involving the lives of others who are also making choices that intersect and overlap with our own. As human beings we make choices, not only with our own needs in mind, but also for the sake of an ‘other’: we choose to spend time with them; to help out; to forgive; to show kindness; to bear with the other in their difficulties. Children are indeed capable of making choices to do with their own wellness, but they especially need the choices of adults to overlap and intersect with their own choosing. The Belgium proposal may appear on the surface to show respect for children and their capacity to choose, but it fails to sufficiently take into account the child’s vulnerability and the child’s need for adults who are called upon to make good choices for their sake.

One of the things that makes a child particularly vulnerable when it comes to making choices is the simple fact that she or he has limited experience. This can impact on how they form an understanding of the situation requiring a decision. A child may not see the whole picture or may not understand fully the various options available to them. A child may be confused in their summing up of a situation. Think, for example, of the child who imagines he is responsible for his parents’ choice to separate. Similarly, a child who is seriously ill may see herself as the cause of her parent’s suffering and think that if she were no longer around her parent’s suffering would be lessened or alleviated. Sophie, in the novel, ‘Gold’, was looking at things in this way. The legal age is set for a very important reason. Children need the protection and care of adults. Children, whose minds are developing and whose experiences are limited need to be protected from the burden of thinking they have both the power and responsibility to make things better for their families.

In fact, all people living with a life-limiting illness need to be protected from this burden. It goes to the heart of why euthanasia is a bad idea for adults as well as children. The claim that an earlier death will somehow make everything alright is a spurious one that is not resolved by a simple appeal to ‘choice’ or the capacity to choose.

Rev Dr Gerard Aynsley is a parish priest in the diocese of Dunedin. He holds a PhD in philosophy from Monash University in Australia