How to deal with the criterion of severe mental distress for late termination of pregnancy? A scoping literature review and a content analysis of clinical ethics consultations.

Background: The issue of late termination of pregnancy (abortion after a certain gestational age, depending on different definitions) is a topic of intense debate among healthcare professionals and the public, as it involves balancing the divergent interests and needs of the pregnant person and the foetus. Some jurisdictions recognize severe mental distress as a valid criterion for allowing late termination of pregnancy. However, the unavailability of a clear definition presents challenges in clinical practice.

Methods: A scoping literature review was conducted to examine how the criterion of severe mental distress is operationalised in the context of late termination of pregnancy. In addition, we conducted a qualitative content analysis of clinical ethics consultation reports dealing with requests for late termination of pregnancy in a Swiss university hospital.

Results: The scoping review of the literature yielded that 23 publications distributed worldwide were relevant to the question. Regarding the concept of severe mental distress, there is no uniform terminology. The indication for abortion is referred to as psychiatric, psychosocial, or sociomedical indication, or maternal emergency. Various criteria are mentioned that can contribute to categorising a condition as a severe mental crisis to varying degrees, including age, psychiatric illnesses, psychological conditions, foetal malformations, socio-economic conditions, or criminological circumstances. The qualitative content analysis of 20 clinical ethics consultation reports revealed a range of ethical challenges that arise in clinical practice, namely how the risk of severe mental distress can be assessed, whether the termination of pregnancy is suitable to avert the distress, and whether the termination of pregnancy is proportionate. We identified several recurring criteria that require clarification to aid decision making, such as whether treatment options and alternatives have been adequately discussed and presented, whether the request is consistent and enduring, and whether there are causes of severe mental distress that could be eliminated otherwise.

Conclusions: For jurisdictions that allow late-term abortion based on severe mental distress, we propose a set of guiding questions to support healthcare professionals engaging in careful decision making.