Judit Sándor
Center for Ethics and Law in Biomedicine, Central European University
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Viola Lászlófi
Center for Ethics and Law in Biomedicine, Central European University
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Hungarian Historical Review Volume 12 Issue 3  (2023):493–523 DOI 10.38145/2023.3.493

In this article, we examine the medical, legal, social, and political context of abortion in Hungary after the Second World War, with special attention to the decision-making process of the so-called abortion committees. These committees collected data on the social and medical status of women to support their decision on whether to permit the operation or not. In the first half of the 1950s and after 1973, the committees were given a relatively free hand in making their decision on whether to allow an abortion. Women had to appear in front of these committees in person, and the process was a performance of demonstrating compliance with the law by stating a legally acceptable reason to terminate the pregnancy. In our article we analyze how the hierarchical-paternalistic structures of healthcare were reproduced and operated in the frequently changing abortion regimes within a state socialist legal and political framework. We also explore how these phenomena affected women’s requests and the options available to doctors at the micro level of decision-making on abortion. The study shows how women and doctors were forced to make efforts to comply with the changing normative framework and how different forms of paternalism (e.g., institutional, medical) shaped this process. The main purpose of the various laws was to regulate abortion and population policy by monitoring the measurable circumstances of pregnancy. In the early 1950s, the focus was on the health of the mother, whereas in the 1970s it was more on the living conditions necessary to raise a child. Despite the detailed regulations based on the paternalist structure of the healthcare system, it was left to doctors and other members of abortion committees to implement the norms at the local level. In some cases, doctors utilized this paternalist framework and patriarchal techniques characteristic of the healthcare system to circumvent the intentions of population policy. The article demonstrates these phenomena by analyzing the medical records of Pesterzsébeti Szülő- és Nőbeteg Otthon (Gynecological and Maternity Hospital of Pesterzsébet) and the documents of the abortion committee of Pécs.

Keywords: Abortion, abortion committee, population policy, legal and medical paternalism

In state-socialist Hungary, paternalism had many meanings, and it had a strong impact on those areas of medicine that dealt with women’s bodies. In all areas of medicine and health care, before the development of bioethics, paternalism permeated the doctor-patient relationship. This relationship was hierarchical, the institution of informed consent was not respected in practice, and even the treatment chosen was not necessarily communicated to the patient. Physicians gave orders to the patients and the patients complied with them. This institutional hierarchy of medical paternalism was combined with a patriarchal form of paternalism in gynecological and obstetrical practice. Although more and more women became doctors in line with the emancipatory intentions of the Communist party-state, these fields remained male-dominated throughout the era of state socialism. In gynecology and obstetrics units, almost exclusively male doctors examined women and made decisions about their bodies which in some cases affected women’s lives irreversibly.

After the socialist transformation of health care, female patients in obstetrics and gynecology units became the subjects of a third form of paternalism that characterized all services provided by the state. From the late 1940s, the Party’s goal of equal and free access to health care was essentially twofold. The Stalinist Constitution of 1949 included free health care among the basic rights of workers, symbolizing the Party’s unlimited concern for the previously neglected layers of society.1 Accordingly, by 1961, with the extension of health insurance, 91 percent of society was eligible for free health care, and by 1972 free health care was accessible to all.2 To achieve this goal, the regime thoroughly centralized the health care system in the early 1950s. Hospitals were nationalized and healthcare workers became state employees. The standardized, efficient operation of state institutions was prioritized over individual concerns, enabling the party-state to extend its control over the body of each and every individual. These changes also clearly embodied, on the institutional level, the notion that the state (in the form of state-funded hospitals and state-employed doctors) knew better than individuals what was good for their wellbeing. In this system, the patient was a passive recipient of medical treatment with little say in the process, which was controlled and managed by a powerful state institution and doctors. We argue that, although abortion regimes changed over time, the complex structure of paternalism in abortion decision-making remained. In practice, however, the paternalistic attitudes of doctors and institutions did not imply full compliance with the law, but allowed doctors to facilitate abortions in some cases where the legal requirements were not fully met. Such assistance, however, did not reduce women’s vulnerability to male doctors and state institutions.

In this context of mainfold paternalism, in this paper we examine the medical, legal, and socio-political landscape of decision-making on abortion in Hungary after the World War II. We focus on how these hierarchical structures were (re)constructed and functioned in the frequently changing abortion regimes within a state socialist legal and political framework. We also consider how these phenomena affected women’s requests and the options available to doctors at the micro level of decision-making about abortion. The study shows how women and doctors were forced to make efforts to comply with the changing normative framework and to shape their arguments and decisions to meet the medical, legal, and social requirements for abortion. The main purpose of the various laws was to regulate abortion and population policy by monitoring the measurable circumstances of pregnancy. In the early 1950s, the focus was on the health of the mother, whereas in the 1970s it was more on the living conditions necessary to raise a child. Despite the detailed regulations based on the hierarchical structure of the healthcare system, it was left to doctors and other members of abortion committees to implement the norms at the local level. In some cases, doctors used the various forms of patriarchy within the healthcare system to circumvent the intentions of the population policy.

Previous research has shown how political and expert (medical, social scientific, sexological, theological) discourses and the multiple actors who influenced these discourses shaped the legalization and prohibition of abortion, the regulation of various contraceptive methods, and the transformation of gender roles in state socialist societies in the second half of the twentieth century. These studies have highlighted the various ways in which experts could influence population policies and measures and, most importantly, shape the state-party’s biopolitical thinking.3 However, the roles of the different forms of paternalistic tendencies, which were inherent characteristics of state socialist systems and the field of medicine more generally, have not yet been profoundly examined in these works. There has also been little focus on the constraints and opportunities for women to assert their interests and the extent to which gynecologists were able to facilitate or hamper women’s efforts to assert their medical interests at the local level of reproductive control. Our study attempts to do this by analyzing some concrete examples.

In examining this phenomenon, we analyze the legal framework of abortion and the implementation of the law in the cases of two abortion committees. We mainly analyze changing legislation (ministerial decrees, statutory regulations, etc.) as the legal basis of these phenomena. We focus on the legislation itself rather than the legislative process, because it was the law that framed the possibilities for women who requested abortions and the prerogatives of the doctors who decided on the requests. We examine the medical records of the Pesterzsébet Maternity Hospital from 1954 and 1956, which include the minutes of the meetings of the abortion committee concerning cases when the requests were accepted, and the documents of the abortion committees of Pécs from 1974, which offer examples of both approvals and rejections. We have about 2,000 cases from Pesterzsébet. From Pécs, we have 631 applications received by the abortion committees. Since neither the documents produced by the committees (e.g., the women’s applications or the reports on living conditions) nor the medical documentation of the patients who underwent abortions had to be handed over to the archives, the types of sources included in our analysis are rarely available in the Hungarian context.4

Abortion Policy in the Rákosi Era and the Creation and Makeup
of Abortion Committees

Abortion became a political issue and thus a matter for the whole country three years after the communist takeover. The slogan of the time was “childbirth for a girl is an honor, for a woman it is a duty.” Three ministers of health served during the period of the strict abortion regime from 1952 to 1956, but the unpopular measures of this regime have come to be associated with the name of the only female minister of the Rákosi era, Anna Ratkó.5 The birth of many unwanted children was attributed to her, and the country associated the “abortion law” with her.6 Anna Ratkó did not ban abortion, as induced miscarriage was already forbidden unless carrying the pregnancy to term endangered the life or health of the mother. Under her ministerial tenure, abortion was allowed, but the conditions under which it could be performed were enshrined in law, outdated practices were abolished, and health considerations were upheld.7

The new policy therefore aimed to enforce the existing but practically ignored norms and bans and control several aspects of pregnancies and all circumstances of their termination, with the active participation of different bodies of the state (including medical authorities and law enforcement). The abortion policy and its drastic measures were supported and endorsed by the top leadership of the Hungarian Workers’ Party. The few circumstances under which abortion was allowed became a political issue and a matter of law enforcement. The police took harsh measures against medical professionals who were performing illegal abortions. As a result, people with no medical qualifications (referred to in the public jargon as “angel makers”) took over the activities of doctors and midwives. This only increased the death toll, and the rising death toll provided an additional justification in the fight against illegal abortion. Moreover, unscrupulous “profiteering” physicians were banned from their profession, and women who had abortions were pilloried sometimes in local newspapers and within their proper community (e.g. workplace).

The campaign against illegal abortions also relied on the active participation of gynecologists and obstetricians working in the nationalized health institutions. The reasons for this were both medical and political. Illegal abortions posed a high health risk, so doctors, who had become state employees in the early 1950s, were expected to support the party’s political goal on a professional basis. Accordingly, the Ministry of Health Order No. 8100-2/1953 defined professional leadership in the fight against abortion as the task of the head of gynecology in every department in the country.8 (See Table 1.) The campaign against illegal abortions primarily targeted midwives, quacks, and women who had self-induced abortions, so doctors involved in illegal abortions were less likely to be convicted. By contrast, doctors were also required to report illegal abortions that had come to their attention or face punishment. They were thus less motivated to participate in illegal abortions or conceal cases of which they had become aware. As a result, doctor-patient trust was damaged and women were less motivated to tell their doctors the truth, even if they were in a life-threatening condition after the procedure.

Table 1. Number and distribution of self-induced abortions in 19529

The new abortion regime not only prosecuted illegal abortions and required doctors to be loyal to the regime rather than to their patients, it also actively built on the paternalistic structures of the doctor-patient relationship. Decree No. 81/34/1952 EüM of May 29, 1952, of Minister of Health Anna Ratkó provided for the procedure for the termination of pregnancy and the establishment and functioning of first and second-instance abortion committees. In a report on the health awareness-raising work two months later, Deputy Minister Miklós Drexler wrote that the committees were established “to eliminate laxity in adjudication” and consisted of trusted professionals. He also noted that, to strengthen supervision, only designated institutions were allowed to perform induced abortions. The ministry considered it necessary for the existing abortion committees to take a “fair” position, as this would make them “more popular, which would be a means of effectively fighting illegal abortion.” However, these committees were made up of doctors and held their hearings in public health facilities, so their very structure made it difficult for women’s interests to be represented and for their claims to be fairly assessed.

According to the procedural rules of Decree No. 81/34/1953 of the Minister of Health, the termination of a pregnancy was only permitted during the first 28 weeks if the termination was necessary to save the life of the pregnant woman or if the life of the unborn child was in serious danger of being harmed. The pregnancy could only be terminated with the pregnant woman’s consent and only in one of the medical establishments listed in the annex to the decree, with the permission of the first or second-instance committee organized for this purpose.

These laws contained the two important features that characterized all abortion laws of the state socialist period, reflecting the party’s intention to gain active control over reproductive decisions. First, like any other basic right, the right to abortion was not regulated by parliamentary acts but by lower-level legal measures, such as decrees issued by the council of ministers (government decrees) or ministerial orders.10 These decrees and ministerial orders introduced and amended rules on the circumstances under which an abortion could be performed. And as subordinate norms, they could easily be changed according to the shifting intentions of the party’s population policy and its measures.

Secondly, women’s opinions and wishes were considered secondary to demographic and ideological concerns, so the regulations concerning abortion mostly focused on the technical issues of who could request an abortion and under what circumstances such a request could be granted. This also meant that the moral and legal positions and arguments characterizing abortion debates in the Western literature a few decades later (such as pro-life11 vs. pro-choice, liberal vs. conservative, or moderate) did not apply to the practice of regulating access to abortion in postwar Hungary. Neither the issue of the legal status of the embryo or fetus (as a living being protected by the law or not) nor women’s rights to bodily self-determination played any role in shaping the legal policies on abortion.12 In other words, once moral and philosophical arguments were removed from legal deliberations on reproduction, the dominant discourse framing abortion became demographic and population policy, so that access to abortion could be granted mainly on material and medical grounds and could be rigorously controlled and constantly reassessed by the state.

This transformation of the law and the practice of abortion was part of the process of Sovietization. Abortion committees had been operating in the Soviet Union since 1936, with similar functions and similar numbers of members. These institutions existed in other socialist countries too, such as Czechoslovakia from 1952.13 The first-instance committee was tasked with establishing the presence of certain pregnancy conditions and authorizing the termination of a pregnancy. An application for permission to terminate a pregnancy had to be submitted in writing or verbally to the head of the competent first-instance committee, and records were kept of these applications. At the verbal hearing, minutes were taken and, if the pregnant woman was under medical or hospital treatment, the minutes were accompanied by the report(s) issued by the treating physician. The first-instance committee made its decision within five days of the application being submitted on the basis of the medical reports submitted and the necessary examinations. If the pregnancy could not be established beyond doubt, the committee could refer the pregnant woman to a hospital for a maximum of eight days, and the committee made its decision based on the report issued by the hospital after the examinations had taken place. The committee kept minutes of the procedure, recording the medical history, examination results, diagnosis, and indications, in addition to the personal details of the pregnant woman. The committee considered whether to approve or reject the request for permission to terminate the pregnancy based on all this information.

If the committee did not grant the request, the applicant was informed immediately, and if she found the committee’s decision objectionable, she could appeal and submit her request to the second-instance committee. The committee sent the minutes, together with the examination report, to the head of the second-instance committee within 24 hours and, after the facts of the given case had been considered, a decision was made whether to overrule the decision of the first committee.

Women whose applications were rejected were subjected to increased surveillance throughout prenatal period, making it impossible for them to terminate a pregnancy illegally. They were granted “heightened protection” by the maternity advisor in the pregnant woman’s place of residence. This rejection also had to be recorded in the pregnant woman’s medical record and her pregnancy booklet. These pregnant women were required to submit themselves to visits by the visiting nurse (who was always a woman) at least six times. When the pregnancy ended, whether in birth or miscarriage, this had to be reported to the council’s health department and, in the case of a birth, information on the status of the baby had to be provided.

If the first-instance committee approved a request to terminate a pregnancy, it sent the minutes together with the results of the examination to the designated hospital and referred the pregnant woman to the same institution. The hospital was required to carry out the termination of the pregnancy immediately after the pregnant woman was admitted, to hospitalize the patient for at least three days, and to report the termination to the chief district obstetrician. The minutes and reports sent by the committee had to be lodged and kept in the hospital’s record office.

The structure of the committees reveals their essential political function, which was to determine the medical necessity of abortion or, more precisely, to control the process by which such decisions were made. The first-level abortion committees consisted of three members and had to be set up in every health institution that had a gynecological department. The chairman was the chief gynecologist of the institution, the permanent member was an internist appointed by the city council, and the third member was chosen by the chairman and the permanent member. The second-level committees were organized in the leading hospitals of each county and Budapest and in the gynecological clinics at the universities. They also had three members, all three of whom were doctors.14

This form of state control over reproductive decisions by abortion committees had a significant impact on the status of women seeking abortion in the whole state-socialist period. Women who requested permission to terminate their pregnancy did not have the same status as patients who wanted the best available treatment. Instead, they were viewed as applicants who wanted something that needed to be assessed and monitored. Consequently, moral and emotional considerations were not listed among possible grounds for termination of a pregnancy. The acceptable reasons for requesting an abortion were only “objective” concerns: health problems and, after 1954, poverty or material deprivation, lack of accommodation or inability to raise children, and health conditions. From 1954, these conditions were assessed by nurses who wrote official reports on the living conditions of the person or people requesting an abortion. These reports were highly subjective, since the state authorities asked only two main questions: who lived together and how many rooms they had in their dwellings. The other parts of the reports were based on the visiting nurses’ subjective assessments. While this lack of regulation could have created opportunities to help women who were seeking abortions, it made the inspection process unpredictable. A visit by one of the nurses was an intrusion by a representative of the state into the intimate sphere of the family or the women, and the nurse could present anything she found as an argument for or against abortion. The committees thus not only exercised control over the bodies of women seeking abortions but also had some control over their broader social environment.

Medicalization of the Social? The Decision-Making Process in the Abortion Committees until 1956

The secondary literature points to two trends in the operation of the abortion committees. First, in the 1950s, the legal framework gave the committees considerable autonomy in their work. Second, on the basis of the statistical data concerning applications and approvals, “women who applied to the first-instance committees were mostly assured of a positive decision.”15 Approximately 80 percent of applications were approved by the first-instance or second-instance committee, even in the early period after the committees were established. In general, however, the secondary literature is unclear about precisely what is meant by the autonomy of the committees and how this autonomy might have worked in practice in the context of the inherent hierarchical and paternalistic structures of the medical field. In the following section, we take this lacuna in the secondary literature as a point of departure and examine whether this autonomy could have offered opportunities to help women in need. We also examine how women maneuvered among these intentions and hierarchies to secure abortions.

Although the committees were strictly regulated, their decisions were made on the basis of professional knowledge, which allowed them to decouple their work to some extent from political intentions. However, this local autonomy did not mean that their decisions were not made in a paternalistic manner. If we take a closer look at how the role of anemia as a medical reason for abortion changed in the medical records of Pesterzsébet, we can see how doctors with decision-making power on the committee could use certain diagnostic categories to facilitate abortion for women in difficult social situations before 1954 and in the first half of that year.16 Anemia was included in the regulation as a legitimate reason for abortion, but it was left to the committees to decide whether cases were serious enough to pose a risk to the life of the mother and fetus and therefore to justify abortion.17 Anemia was one of the relatively rare causes of abortion at the national level, along with rubella and Addison’s disease. In the Pesterzsébet cases, while anemia and mental illness were among the accepted reasons for abortion in the first few months of 1954,18 in the second half of the year, the first-instance committees rejected applications in which anemia was used as a reason for abortion (see Table 2). After a request for permission to terminate a pregnancy had been rejected, the case was sent to the second-instance committee and approved without exception, but on social rather than medical grounds.

Table 2. Number and reasons for abortion in 1954 in Pesterzsébet19

In the case of anemia, the social causes of the disease explained the interchangeability of medical and social reasons of abortion. Poverty and resulting malnutrition were major causes of anemia, but while this diagnosis was an acceptable reason for abortion even under the strictest abortion regimes, poor social conditions did not become acceptable until 1954. The devastation caused by World War II and the poor economic policies of the State Party in the early years of state socialism had affected a large segment of society. Food shortages, the lack of basic necessities, and inadequate housing became parts of everyday life. This put women in a particularly difficult situation. With the birth of another child, a family had an extra person to feed, pushing them even deeper into poverty.20 Under such conditions, anemia was often present, and this offered doctors a medical basis for allowing abortions. In other words, this diagnosis functioned as a kind of medical metaphor for poverty. Thus, when abortion became legal for social reasons, it lost its function.

It is not clear, however, whether the diagnosis of anemia was serious enough to justify the termination of a pregnancy strictly on medical grounds. As early as the 1930s, Hungarian medical journals had published studies describing the uncomplicated but successful treatment of anemia in pregnant women.21 These articles presented cases from both urban and rural public hospitals, indicating that the method was available to a broader segment of society, not only the elite.22 Although archival documents show that Hungary suffered a shortage of medicines in the 1950s, this shortage did not affect the treatment of anemia. 23 Therefore, the professional and legal duty of doctors should have been to treat the patients, not to terminate their pregnancies. What the existing treatment could not change was the social and economic environment in which the disease developed and in which its patients had to live. Consequently, if doctors could ignore certain professional norms and forms of treatment, they could use the diagnosis of anemia to medicalize a devastating material circumstance and help women in a difficult situation.

The excessive medicalization of the different types of problems was not only a tool to help women in need; it also highlighted how difficult it was to adapt to the changing legal environment in practice. When the second-instance committees were allowed to authorize abortion on social grounds, the new role of the first-instance committees was not redefined. Consequently, the medical and social reasons became strictly separated, but in practice it was not possible to draw such a clear distinction between the two categories. From April 1954, several cases were referred to the second-instance committee in which the reason for the first-instance rejection was the diagnosis of neurasthenia. The decision was not surprising. While the consideration of mental problems as a reason for abortion was not far from the Party’s thinking or the general tendencies toward abortion, neurasthenia was not mentioned as a legitimate reason for abortion in Decree No. 1004/1953 (II.8.) of the Minister of Health.24 The process of diagnosis, however, did not follow the legal and medical requirements. Instead of entrusting the decision to a specialist (a psychiatrist) and taking his or her opinion into consideration, the committees had made the diagnoses during the hearing. Why did the first-instance committee find it important to establish an unacceptable diagnosis as the reason for the abortion when it was highly probable that the request would be granted on social grounds?

The answer lay both in the specific situation of neurasthenia in the Hungarian health care system and in the situation of the first-instance committees in a changing legal environment. The contemporary scholarship used neurasthenia as a substitute for medically unexamined and untreated problems. This diagnosis has been criticized, since patients with chronic fatigue, dizziness, headaches, loss of appetite, or nausea (symptoms which could not be easily attributed to a specific disease) were diagnosed with and treated for neurasthenia instead of being subjected to further testing. These symptoms also occur in the early stages of pregnancy.25 From a psychiatric point of view, neurasthenia could also have been caused by nervous exhaustion as a result of a lifestyle of deprivation and difficult social circumstances, which affected a large part of society. 26 Neurasthenia, therefore, had both medical and social causes, but it was not determined by adequate testing or expert opinion. In other words, the distinction between social and medical categories was not as clear in medical practice as it was in law. The role of the first-instance committees diminished as more applications were made on social grounds, leaving them more capacity to deal with minor medical problems. A diagnosis of neurasthenia could justify a hearing on medical grounds.

The role of neurasthenia and anemia is comparable and shows how the same paternalistic diagnostic process could lead to very different outcomes. In both cases, the diagnosis was based on conditions that were not necessarily medically pathological. However, the diagnosis was not questioned by anyone because it was made by doctors in a position of professional and social authority.27 In the case of anemia, this helped women in need to have an abortion. In the case of neurasthenia, doctors made a psychiatric diagnosis which was not curable, and which did not present symptoms that might have had a major impact on social integration, but which, as a psychiatric diagnosis, could lead to social stigmatization.

These local decision-making practices show that women had to be familiar with a number of circumstances in addition to the changing legal environment in order to negotiate their requests for abortions successfully. In the course of our research, we found 25 letters written to the committees by women seeking abortions between January 16 and December 15, 1954, during a period when poor social conditions were becoming a legitimate reason for abortion.28 These letters show that although women were apparently able to adapt their claims quickly to the changing legal environment, they had little chance of knowing with any degree of certainty whether their requests would be approved. 20 out of the 25 letters included social reasons for abortion. In the arguments used in these letters, poor housing conditions and low income are recurring elements which highlight the shortcomings of the party-state’s social policy and illustrate the fact that, despite the propagated prioritization of population policy and the wellbeing of previously neglected social groups (e.g., workers), the party was not able to create adequate economic conditions for many women to have children. Another element of the law is also reflected in the letters. 24 out of the 25 applications mentioned a medical reason as grounds for the request for permission to terminate the pregnancy.

In addition to the social and medical reasons, the letters described the women’s emotional difficulties. These emotional aspects of the narratives are the most revealing from the perspective of the precariousness of the women’s circumstances, even though they appear in only about 20 percent of the applications. The fear of not being able to spend enough time with a sick child, the intense grief over the death of parents, or, in two cases, the emotional distress and vulnerability caused by an unfaithful husband were cited as specific reasons. From the perspective of privacy, the inclusion of these kinds of details allowed the committee members to invade the women’s most private spheres. It suggests, furthermore, that the women did not fully trust that their requests would be considered according to the rules and felt that they were protecting themselves by presenting their situations as matter for individual consideration.

The letters show that women were not sure how their requests would be treated, even if they were living under challenging material circumstances that gave them reason to expect a positive response. This suggests that even though they were aware of the changes in the law, they had no trust in a predictable decision and used any possible reason in the hopes of securing permission to get an abortion. The distrust expressed in the letters did not diminish over the course of the year, and the accumulation of arguments in support of requests did not decrease in the slightest.

Abortion Policy after 1956

A turnaround in the regulation of abortion came when, in Decision No. 1047/1956 (VI.3.) of the Council of Ministers, the “insistence on abortion at all costs” was added, alongside illness and social reasons, to the justifications for seeking an abortion.29 Interestingly, this reasoning appears as an explanation in various time periods in the doctor-patient relationship, together with a slogan frequently cited by gynecologists according to which, “women would do everything to be a mother and not to be a mother.” In his memoir, Zoltán Papp, a professor of gynecology and obstetrics and head of the Teaching Hospital at the Medical School in Budapest, also cites this phrase,30 and although he mentions several issues of the doctor-patient relationship in the context of gynecology, such as the questions of in vitro fertilization, caesarean section, and the genetic condition of intersexuality, he spares only one sentence on abortion by stating that the doctors simply have to accept the fact that at times women insist on having abortions.

Parallel to the dissolution of the Rákosi era in Hungary after Stalin’s death but only a few months before the outbreak of the 1956 Revolution, the ban on abortion was abolished by a decree of the Council of Ministers, and abortion was liberalized according to the Soviet model. This change was part of the relaxation following the 20th Congress of the Communist Party of the Soviet Union in February 1956. At this congress, the cult of personality and the dictatorship of Stalin were denounced. This critical tone of the Soviet regime had an impact on the situation in Hungary. Although the process had already begun in 1954 with the acceptance of poor social conditions as a reason for abortion, the further relaxation of abortion regulations can be seen in this context. This transformation was linked to József Román, Minister of Health at the time, who introduced the decision by stating that “women’s perseverance in all areas of our economy, their advanced self-awareness, and their sacrificial attachment to family and child, typical of the great majority, have created a moral basis for women to decide for themselves on the question of motherhood.”31 This phrasing also put the responsibility on women, but most likely this turn acknowledged the sad fact that the combination of a lack of adequate family planning and the repressive abortion policy created many victims of illegal abortions and unwanted children. Based on the Health Minister’ s decree no 2/1956. (VI. 24.) on the regulation of the procedure related to the termination of pregnancy, the committee authorized abortions if it was necessary to save the life of the pregnant woman or to protect her from a serious illness or further aggravation of an existing illness or if the unborn fetus was in predictable danger of serious damage. The committee was also authorized to allow the termination of a pregnancy if it was justified by personal and family circumstances that deserved consideration or the applicant insisted on the termination of the pregnancy even after having been informed about the consequences. In practice, this meant that anyone could terminate a pregnancy by the end of the first trimester.

The new law may give the impression that the state had been forced to revise its pronatalist intentions. However, in the context of the expanding welfare policies of the 1960s, the new law could be seen as a change on the level of policy rather than a fundamental change in pronatalist aims. Until 1956, the main objective had been the birth of every child conceived. Then, and especially from the 1960s onwards, the party sought to encourage the deliberate bearing of children. Instead of banning abortion, the new reproductive regime encouraged women to pursue pronatalist goals and to cooperate with the state. Compared to the first decade after World War II, the community care systems (health care, children’s institutions) were expanded from the beginning of the 1960s. New forms of support were also introduced, such as the childcare allowance from 1967 and a national network of specialist counsellors to help young mothers. State control over reproduction was maintained through the expansion of state assistance and financial support for childrearing, rather than through the hierarchical and paternalistic structures of state-funded health institutions and the doctor-patient relationship.

Although state socialist Hungary, like other states in the Soviet sphere of interest, legalized wide access to abortion before capitalist countries, timing was not the only difference between the two political camps in Cold War Europe. In the USSR from 1955, in Bulgaria, Poland, and Hungary from 1956, and in Czechoslovakia and Romania from 1957 women did not have to meet any social or medical criteria to terminate their pregnancies.32 In Great Britain, France, Italy, and other Western societies, women were not legally allowed to have abortions until the late 1960s and 1970s, when modern contraception was more widely available and new regulations had emerged from social movements and bottom-up feminist initiatives.33 As a result, the right to abortion in state socialist states was seen as given by the state party, which also meant that restrictions on abortion were in the hands of the party-state and that the situations of women seeking abortions were different from the situations of women seeking abortions in the West. This became apparent from the mid-1960s, when the negative impact of high abortion rates on population numbers became central to political discourse in these countries. As a result, abortion in Hungary was again made subject to stricter medical and social conditions in 1973, as the position of those opposed to allowing a pregnant woman almost complete freedom in the decision to have an abortion.34

Abortion Policy after 1973

By the end of the 1960s, the number of abortions had increased dramatically in Hungary. In 1960, the average abortion rate was 66.3 per 1,000 women of reproductive age, rising to 76.5 by 1968.35 Policymakers were eager to find a way of bringing this number down. A new, stricter law was adopted: Decree No. 4/1973. (XII. 1.) of the Minister of Health.36 According to this decree, there were ten reasons for which a pregnant woman could be given permission to have an abortion.

The Health Care Act of 1972, passed a year before the new abortion legislation, changed the hierarchical doctor-patient relationship to some extent. It was a high-level and comprehensive law, which included the duty to provide care and the obligation to share some basic information with patients. It was not very detailed, however, when it came to patients’ rights, as it focused mainly on the duties of the physicians. A special Section was dedicated to the protection of women and mothers.

Article 29 of the Act stipulates that, “[t]he state also ensures the protection of the mother and the fetus with modern health care, as well as the preparation of the pregnant woman for motherhood. In order for the women to give birth to a healthy child, women must be provided with the necessary care and medical care, as well as counseling to resolve specific issues related to marriage and family planning.”

In the second paragraph of this Article, the law orders that “[t]he pregnant woman must be provided with curative and preventive care appropriate to her physiological condition, within the framework of which the pregnant woman is taken into care, the appropriate screening tests, the necessary treatment and counseling. The care must ensure the protection of the pregnancy and the health and development of the unborn child, taking into account the physiological state of the pregnant woman, possible illness, age, and working and living conditions.”

It is striking that in the Parliamentary Act only a short sentence refers to induced abortion: “Termination of pregnancy is permitted only in cases and in accordance with the provisions of the law. The pregnancy must not be terminated if the termination of the pregnancy endangers the woman’s life or may cause serious health damage.”37

Looking at the detailed regulatory grounds included in Decree No. 4/1973 of the Minister of Health on requests for abortions, the bulk of the reasons for which an abortion could be granted involved financial grounds, or the so-called “social reasons”:

Article 1. Artificial termination of pregnancy may be performed upon the written request of the pregnant woman, based on permission. The application is judged by the committee established for this purpose.

Article 2 (1) The committee grants permission for the artificial termination of pregnancy if:

a) a medical reason existing in the parents, or the probable medical condition of the unborn child justifies it,

b) the woman is not married or has been living separately for at least six months continuously,

c) pregnancy is a consequence of a crime,

d) the pregnant woman, or her spouse, does not have her or his own apartment that can be moved into or an independent rented apartment,

e) the pregnant woman has three or more children or has given birth; or has two living children and has also had at least one obstetric event,

f) the pregnant woman has reached the age of 40.

(2) In addition to the reasons listed in paragraph (1), the committee may grant permission to terminate a pregnancy if:

a) the pregnant woman has two living children, but the viability and development of the unborn fetus is expected to be at risk from a health point of view,

b) the spouse of the pregnant woman performs long-term regular or special service in the armed forces or bodies, and at least six months of that time remains to be served at the time of submitting the application,

c) the pregnant woman or her spouse is serving an enforceable prison sentence of at least six months,

d) other social reasons strongly support it.

The committee could authorize the termination of a pregnancy if the pregnancy had not exceeded the twelfth week. Furthermore, permission could be granted to terminate a pregnancy in the case of a minor up to the eighteenth week of pregnancy.

This transformation was the result of a recurring social concern according to which abortion was seen not only as a difficult private decision with an emotional and moral element but rather as an economic decision.38 In sharp contrast with the cases in which women tried to seek help in the 1950s and stated multiple reasons for seeking abortion, often emphasizing their poor health, in cases after 1973, when women applied for permission to terminate a pregnancy after the law restricted their access to abortion once again, they were often stating simple economic reasons. Quality of life had improved in general, and health conditions that had dominated the period after the war, such a tuberculosis, polio, and typhus, had gradually disappeared, but a certain level of material wealth seen as adequate to create a home environment in which a healthy child could be raised was regarded as necessary, including a dwelling or a salary. Although oral contraceptives were already available in the 1970s, abortion was still considered a family planning method for many women. To obtain a prescription for contraception, women had to visit a doctor, which also involved informal payment (so-called hálapénz, or “gratitude money”), but regular gynecological checkups were not compulsory.

From Medical to Social? The Functioning of Abortion Committees after 1973

The new regulation contained new elements. First, in contrast to the Ratkó era, the new law was based not only on a quantitative but also on a qualitative goal: it sought to make abortion more difficult for those who were wealthier. Better financial status could also mean that parents were more respected members of socialist society, so encouraging them to have children was also a tool to shape society and increase the number of individuals with politically and socially appropriate values. Second, in contrast to the period after 1956, different forms of financial support were no longer considered sufficient to motivate people to have children, and prohibitions were again used as an instrument of population policy. In order better to monitor the social and material situation of a pregnant woman as a reason for abortion, the regulations on abortion committees were substantially amended. While in the 1950s, all three members of the first-instance abortion committee had to be doctors, in 1973, only the chairmen of the committees had to be physicians, and although they were doctors, they were chosen by the city’s political leaders.39 Consequently, their selection for the role could be influenced by their political rather than their professional qualifications. The second member was a representative of the city council, also politically appointed, and the third was a visiting nurse. The committee members were thus personally connected to the political leadership, but at the same time, the participation of the visiting nurses on the committee added a female perspective to the decision-making process (as noted earlier, these nurses were always female). Abortion has undoubtedly become a social and material issue rather than a medical one, and the new composition of the committee shows that the party’s thinking on who had the right to decide on abortion and on what basis had changed over the course of the 13 years that had since elapsed.

The standardization of the application form and the report on living conditions was a crucial element of this change. All women were required to provide information about their family’s financial and housing situation, details concerning previous pregnancies (if any), and the contraceptive method that they were using. In cases in which women applied for an abortion on social grounds, an official report on their living conditions was requested to prove that their situations were difficult.40 The medical records of Pesterzsébet already contained some reports on living conditions from the Rákosi era, so the practice was not new, but in the 1950s, only a few applications had included such documents.

The report on living conditions was based on a series of questions, each of which had to be answered prior to the interview during a personal visit by a visiting nurse, so there was no way of limiting the invasion of privacy by the state. The visiting nurse had to gather information according to an official list of questions. She asked about the condition and size of the dwellings, who the women lived with, what they wore, whether they had credit, and the quality of the family’s diet. The nature of these questions illustrates the declining importance of medical data and the rise of personal information in decision-making. As a result of this shift in the application and decision-making process, medical paternalism was replaced by other forms (social, political) of paternalistic control.

How did this new structure of decision-making control abortion at the institutional level, and what impact did these new practices have on women’s applications? To answer these questions, we examined the applications discussed by one of the abortion committees in Pécs in 1973. Under state socialism, Pécs became one of the most important industrial centers of Hungary. Ore extraction, especially coal and uranium, grew rapidly. As a result, the population of the city increased dramatically. Pécs became one of the four largest municipalities in Hungary, with more than 100,000 inhabitants by 1960.41 The city had two abortion committees, one at the Medical University and the other at the County Hospital. The records of the latter committee have been preserved only from the year immediately following the introduction of the new regulation.

Among the documents from Pécs, there are some applications where the standardized procedure was not applied. In these cases, the visiting nurse member of the committee only verbally confirmed the poor conditions at the hearing without an actual report on living conditions, and this confirmation was enough to prompt or allow the committee to approve the application.42 The primary role of these women as public servants was to provide professional, government-funded assistance to mothers providing care for their newborns.43 From the perspective of the committee, the nurses’ verbal testimony about the social conditions of their former clients seemed credible and saved time by allowing the committee to forego any actual report on the circumstances in the applicant’s home. Despite the different motives, the verbal testimony of the visiting nurses could successfully support the women’s credibility in the decision-making process and ultimately spare women any physical intrusion into their homes.

The interpretation of social reasons also changed to some extent between the 1950s and the 1970s. While poverty and poor housing conditions dominated this category, personal intentions to meet the new expectations placed on the ideal socialist woman also emerged. A new trend was the expression by women of the intention to continue their studies. Since women’s education and social mobility were important social goals of the system, pregnant women could see this insistence on the importance of their educational aspirations as an acceptable justification, as it touched both on their personal lives and on the political and social goals of socialism.

Although the new regulation emphasized standardized decision-making, the committees retained considerable autonomy in their work. As a result, it was not certain that a reason which was seen as acceptable in one case would be adequate in another. The first two columns of Table 3 are illustrative. While a 19-year-old unmarried woman with a steady income would be allowed to terminate her pregnancy to continue her education, this was not an acceptable argument for a girl in a similar situation without a steady income. The difference cannot be explained by the law, which would not have allowed abortion in either case. Nor does the financial situation of the women explain the differences, since a woman without a steady income was denied in both cases. Similarly, a change in the composition of the committee cannot justify a different decision in similar situations, since the members of the committee were elected for a few years.

Table 3. Two examples of how the committees treated similar cases differently 44

The most reasonable explanation seems to be that the committee did not even try to be consistent, and it judged each situation individually. Due to different perceptions of individual situations, already controversial issues, such as the situation of women graduates, could be judged differently in each case. Political support for women’s participation in higher education was an argument for accepting such petitions. At the same time, women’s intellectual aspirations were not always accepted, nor did they always enjoy unambiguous support among various segments of society.45

There were also cases in which the reasons for abortion authorized by the ministerial decree were overruled by the committees. Separation offers a good example. The committees could authorize abortion for separated couples, but only if the man and woman had been separated for at least six months. In practice, as the third column of Table 3 shows, the committee could authorize an abortion after three days of separation without considering other reasons, while for another couple, a longer separation might not be seen as an adequate justification for an abortion. In another example, where there were two children, separation was not even necessary. The mention of an allegedly bad marriage was sufficient grounds for an abortion. These requests were discussed within a year, a relatively short period of time, showing that, as had been the case in the first half of the 1950s, women seeking abortions could not be sure of the outcome when they applied for permission to terminate a pregnancy. This also suggests that the bureaucratization of the application process and the standardization of the measurement of social deprivation did not make the process fully transparent. Despite their reduced medical character, the committees, as state institutions, were still able to exercise effective control over women’s bodies, in some cases in ways that differed from the party’s intentions. These committees thus offered women no clear assurance of the outcome of their requests for permission to terminate an abortion and also sabotaged, at least to some extent, the regime’s population policies.

Conclusion and Legacy

We have explored in this article how different regulatory regimes were based on different forms of paternalism and how they influenced the practice of abortion at the local level of health services. The frequent changes in legislation suggest that the State Party in Hungary gave abortion regulation a decisive role over other means of achieving population growth. The constant legal transformation reflects uncertainty about whether a ban on abortion or more permissive regulation combined financial incentives for women to have children would achieve this objective. However, empirical sources show that, from the early 1950s on, the new population policy not only built on the paternalistic structures of the medical encounter but also placed doctors at the center of the anti-abortion struggle by making them state employees and establishing abortion committees. To a certain extent, this also allowed gynecologists and obstetricians to sabotage the state’s population policy by exploiting their freedom of judgement and their status as representatives of the medical sciences whose knowledge was beyond dispute. The paternalistic logic of these decisions did not change over the course of the state socialist period, despite the standardization of the procedure in the 1970s. The involvement of visiting nurses and council members in the work of the abortion committees from 1973 onwards also failed to reduce the arbitrariness of the decision-making process. This made the system unpredictable and placed women in an even more vulnerable and uncertain position.

After the regime change in 1990, a new abortion law was adopted.46 The fierce debate between 1991 and 1992 in Hungary, which was not without some extremes, finally concluded with the drafting of a law based on compromise. A law with such a profound influence on the lives of people and families should, in our assessment, remain in force for a longer period of time in order to create a predictable environment in which legislation can be consistently applied. A country’s abortion law cannot be changed over and over again. In addition to lasting and predictable legal regulation, the requirement of legal certainty also includes the harmony among laws, so that the answers to a given legal question provided by different laws are coherent. In 1992, a new Parliamentary Act was adopted in Hungary, the first regulating the termination of pregnancy in a law that was adopted by the Parliament. The title of the act is somewhat confusing as it refers to the protection of fetal life.47 According to the law, “pregnancy may only be terminated if it is endangered or if the woman is in a severe crisis situation, under the circumstances laid down in the present act.”48 The law defines the severe crisis situation as “a situation that causes bodily or psychological disarray or renders the woman’s social existence impossible.”

Marital rape was only criminalized in 1997 by Parliamentary Act No LXXIII., which went into effect on September 15, 1997. In the same year, a new Health Act49 was adopted that included explicit patients’ rights, including more detailed provisions on informed consent and some reproductive rights.

In Hungary, abortion continues to be a subject of biopolitical debates. Recently, in a measure that hearkens back to socialist times with the adoption of a low-level legal norm, the Appendix of a decree prescribed new conditions for abortion in 2022 which included compulsory examination of fetal life signs, such as a heartbeat.50 This measure again disrupts the doctor-patient relationship in the vulnerable field of reproductive rights. Although the abortion committees were dissolved even before the regime change and relatively broad access to abortion was granted in the 1992 Parliamentary Act, paternalism still dominates the field of reproductive rights, which operates with laconic but significant changes to the law which are symptomatic of legal and medical paternalism. In addition, pronatalist policies also took the form of patriarchal policies that include not only propaganda but a certain level of coercion. Although women now do not have to stand in front of abortion committees, they have to go through a double consultation process of which paternalism is still very much an element.

Acknowledgements

The writing of this article, which is part of the project “Taming the European Leviathan: The Legacy of Post-War Medicine and the Common Good,” was supported by the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement No. 854503).

Archival Sources

Magyar Nemzeti Levéltár Országos Levéltára [National Archives of Hungary] (MNL OL)

M-KS 276. 96. Magyar Dolgozók Pártja és a Magyar Szocialista Munkáspárt iratai, MDP központi szervei, Adminisztratív Osztály iratai [Documents of the Hungarian Workers’ Party (MDP) and the Hungarian Socialist Workers’ Party (MSZMP), Administrative Department of MDP]

Magyar Nemzeti Levéltár Baranya Megyei Levéltára [National Archives of Hungary, Baranya County Archives] (MNL BAML)

XXIII. 158. e. Terhességmegszakítást Elbíráló Bizottság iratai [Documents of the Abortion Committees]

Budapest Főváros Levéltára [Budapest City Archives] (BFL)

VIII.1144 Pesterzsébet Város Szülő- és Nőbeteg Otthona iratai [Documents of the Pesterzsébet Maternity Hospital]

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