The Physician's Perspective

SINCE IT is the doctor who finally recommends or pefforms medical abortions, the major issue for the medical profession is whether doctors should have more freedom under the law to follow their inclinations and their consciences. Moreover, the considerations for the doctor on whether to recommend an abortion have become increasingly complex as the frame of reference for medical decisions has broadened.

The concern of medicine increasingly is not only with disease and death but with health as well. The modern concept of health is that of a positive state of general well-being, and not just an absence of disease. The World Health Organization has described health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease or inlirmity."

"This concern with health," Dr. Kenneth J. Ryan, chairman of the Obstetrics and Gynecology Department at Western Reserve University, has written, "is both individual and group directed and the distinctions of social and medical, or physical and mental, illness cannot be sharply defined."

What this means in terms of abortion is that there is a broader, and less distinguishable, set of circumstances which a physician considers when he considers granting an abortion than simply whether the woman is likely to die, or to become seriously disabled. As Dr. Ryan wrote:
    Pregnancy poses many threats to the mother and the family unit which are outside the "traditional" realm of medical practice but well within this expanded concept. These pregnancy "threats" are variously the consequence of: poverty, the broken or unstable family, illegitimacy, rape, incest, social and religious pressures, age, psychic disturances, conflicts regarding the use of contraception, chronic illness, and fear for the welfare of the unborn child. Although none of these may be life-threatening, they are life-devastating, so apparently life-devastating that throughout the world, even in countries with "liberal" abortion laws, women desperately seek, and usually obtain, abortion by any means possible (even at considerable risk to life). It is not the pregnancy that is necessarily so terrifying as the sequelae. The pregnant woman with heart disease may not die while hospitalized for six months for optimal care but she may not be able to care for the child normally or see it reach full maturity. Living with children in poverty that sustains a attern ol futility of life, living with a hopelessly deformed or retarded child or bearing an illegitimate one is a life situation that many pregnant women will not accept. This is a medical and social fact, moral, legal, and religious issues notwithstanding.

    In short, a physician cannot for practical purposes list a group of "disease states" or conditions as medical indications for abortion. There are no absolute medical indications except those based upon a set in the scale of values of maternal versus child welfare, and the prevailing attitude of society on the sanctity of the developing fetus. Physicians, however, are not indifferent to the needs of these desperate pregnant women and for the most part have supported more liberal indications for therapeutic abortion, based upon risk to the mother's life and health in the broadest sense. It must, however, be clearly realized that terrnination of an unwanted pregnancy will not often affect the underlying disturbance that provoked abortion. Abortion merely interrupts an acute episode in what may be a more fundamental recurrent or chronic disease, be it a social behavior, poverty, or mental illness. Other forms of therapy are sorely needed, induding prevention of unwanted pregnancy by exercise of personal responsibility and the use of contraception.
So much for the broad context in which the physician makes his decision. There are also some pertinent medical facts which shed light on the physician's role. First, the organic grounds for therapeutic abortions (heart disease, epilepsy, diabetes, and others) have diminished.

Second, the instances in which pregnancy might result in the mother's death have also diminished. But there are also instances, which are now somewhat better understood, in which her life expectancy may be foreshortened by bringing the baby to term, or in which her 'health," in the broader sense, may be impaired.

Third, the number of women who become pregnant as a result of rape, if one includes unreported rapes, is probably about 750 a year. If a woman goes to a hospital within five days or so after being raped (after conception but before implantation) and requests a D and C (dilatation and curettage, in which the womb is scraped), she can receive one. This is generally considered to present no legal problem-that is, there will be no prosecution. Many women, however, for a variety of reasons do not report to a hospital within this time, and with the exception of the three recently enacted state laws, no state laws permit abortions because of rape. Therefore, under current circumstances, the rape victim who seeks a legal abortion at a later date is likely to have to prove, before the law, that the rape took place, and, before the hospital board, that her mental health is at stake.

Fourth, the development of abortifacient pills will have a further complicating impact on the entire abortion picture. Physicians believe as a general principle that the prevention of fertilization through contraception is far preferable to any measures taken after the fact. Nevertheless there are now in various stages of development several possible methods of preventing or aborting a pregnancy after intercourse through use of pills. It is believed already possible to do this through taking a series of high-dosage hormone pills for a few days, within a few days after intercourse. There may well be developed what is refereed to as the "morning-after" pill, a pill which if taken within a few hours after intercourse' prevents the fertilized ovum from being implanted in the uterus. There may also be developed a pill which, if taken on the twenty- eighth day of each menstrual cycle, can end a pregnancy begun during the cycle. Whether or when such drugs will be widely available is only a matter of conjecture at this point. One continuing problem may be their safety for both the mother and the embryo (there would have to be certainty that the pills would always work, lest instead of destroying the embryo they might just damage it severely). But the overriding point is that if developed so as to work safely, these abortifacients would, in removing the clinical aspects of abortion, diminish further the law's ability to control abortions.

Fifth, sterilization may develop as an alternative, in some cases, to abortion. Many hospitals offer the option of sterilization to women who have had a number of children and express a desire for not having more. Some suggest that if a woman who has had children wants to be sterilized, it would be preferable to permit this than to cause her to seek an abortion in the future.

Sixth, it is of interest that the death rates from abortion vary widely from country to country. The lack of a valid reporting system in the United States has been covered in Chapter 4, "The Statistical Background." The death rate in Sandinavia is about 1 in 2,500. The death rate in Eastern Europe is about 1 in 25,000. Reasons suggested by doctors for the lower death rates in Eastern Europe are that the grounds for abortion in Scandinavia are stricter and therefore a higher proportion of sick women undergo them there; that abortions tend to be done earlier in pregnancy in Eastern Europe; and that the method of aborting in Eastern Europe is a newer vacuum method, as opposed to the traditional D and C.

One important set of issues before the physicians in abortion cases revolves around the decision whether they have one patient--the mother--or two--the mother and the fetus. Probably the great majority believe the latter to be the case. This raises, in turn, difficult questions about the relative consideration which the physician should give to each of the two patients.

The medical point of view has long heen that there are two patients. The geneticists tell us that the genetic material to produce an adult is in the fertilized egg. "It doesn't matter," said a geneticist, "whether it is at three months of pregnancy, at birth, or at ten years of are destroying the same human being." Biologically, therefore, human development is a continuous process from conception to birth and beyond. However, there are medical and medical-legal differences attached to the fetus at different stages. The fetus aborted--naturally (in a miscarriage) or in an induced abortion-before twenty weeks does not require a birth, death, or stillbirth certificate, does not require legal interment, and is treated as a pathological specimen. After twenty weeks recordings of birth and death are required. In addition, there are strong cultural forces which have resulted in less emotional investment in the loss of a fetus than in the loss of an infant in childbirth. For many, therefore, the previable fetus-the fetus that could not survive outside of the mother--is not a "human being," in spite of the fact that it is part of the biological, and, to many, spiritual, continuum of mankind. The actual point of viability is moving back in time, but not to the degree often suggested by nonmedical experts. The youngest fetus said to have ever survived outside of the mother was about twenty weeks old.

There is disagreement over what this information means when it comes to actual abortion cases. Some doctors argue that for these biological reasons it is artificial to try to find a point in time where one could establish the "humanness" of the fetus, that one is talking about a child and a parent and must proceed in his considerations from there. It is wrong, in this view, to consider the parent without respect to the fetus; and it is equally wrong to consider the fetus without respect to the parent. One gynecologist, however, argues that "the fetus or the mother is the issue in a very small percentage of the cases we consider; it is more often the fetus and the family or the fetus and the community. When this baby is born will it undermine the family or the community-that's the most important decision to make. In the case of the defective child, is it life, or is it living, that we want to support?"

Dr. Sophia J. Kleegman, Professor of Obstetrics and Gynecology at the New York University College of Medicine, has written:
    Much has been written about the rights of the fetus versus the rights of the mother. Little or nothing has been said about the rights of the family to be allowed to maintain some stability and to offer a healthy emotional climate for the growth of the child. The rights of the fetus should also include the right to be born with sufficient physical, mental, and emotional endowment to have the minimum potential for living. The community also has the right to have families who can raise responsible citizens, and the recipocal responsibility to offer the necessary essentials to those families, including the socioeconomic and total health requisites.
(This is the philosophy behind the Sandinavian abortion laws. The purpose of the laws is to encourage women who want abortions to come to welfare centers, where the entire range of their family problems can be dealt with. It has been pointed out that under the more restrictive United States system many women who want abortions do not seek, or receive, any of these kinds of help.)

Yet, other doctors would take these same facts about biology and societal attitudes and establish a quite different frame of reference in considering abortion. One said:
    If you use the analogy of the life-support system of individuals you find a continuum of attitudes of society-from the life-support system of the astronaut to the life-support system of the early fertilized ovum. If we have for example an astronaut in space and someone comes along and shuts off the oxygen supply, this would be called murder, no question about it. If you take the baby whose life support is dependent upon adequate feeding (we know if babies are not fed adequately they dwindle and die), the term here is not "murder," it is "neglect." You go to the younger premature infant and you don't give its life-support systems proper help so that it does not get adequate oxygen; this is called "poor medical care." You go back a little further and society uses the term "abortion," which has nothing to do 'with the fetus being killed. You go a little further and you have no term for the ovum just fertilized that is not allowed to develop. Some people say it is contraception. I think many of us believe the IUD (intrauterine device) is preventing implantation. So it shows the adult view of what is important. We assign a greater value to life the more it resembles ourselves. The thing I have objected to is that until very recently parents could fatally injure their children and get away with it and it has only been recently that we have had concern with somebody sticking up for the baby who is born. Someone has to stick up for this baby before it is born.
In this view, the very facts that, biologically, life is considered to begin at conception, and that society does not take the nonviable fetus as seriously as a viable, or newborn infant, make it incumbent upon the medical profession to weigh the evidence heavily on the side of the fetus.

The Defective Child

The aspect of abortion which causes some of the most troubling questions is the abortion of the potentially defective child. There are strong reasons for sympathy with parents who do not want to bring a defective child into the world: the life a seriously defective child has to lead has been referred to by some as a "living death"; a family which must care for a seriously defective child may undergo serious strains.

Yet to decide to abort a potentially defective child involves making other very difficult and serious decisions: that a certain degree of defect is or is not tolerable; that the possibility of a certain degree of defect is or is not tolerable; that someone else's life is or is not worth living.

To a very great extent, these decisions involve moral and ethical rather than medical issues. Many believe that a decision to abort because a child might not be the physical or mental equal of other children undermines reverence for life. Others feel that it is immoral to recognize life per se as the sole value. As one participant put it, "Medicine must preserve health, including health of the family, as part of the total life." Yet who is to make these decisions? The legal changes that are being proposed would permit the parents to decide. Yet there are many who fear that such permissiveness will, implicitly or explicity, lead to societal decisions that certain-kinds of children ought not to be born, or even ought not to be permitted to live, and they argue that such decisions have no basis in morality.

There are several generally held misconceptions about abortion of the potentially defective child. One misconception is that such cases represent more than a minor fraction of all abortions being performed. Another is that many retarded children can be diagnosed before birth. As of now, and in the near future, only rarely can or will medical science be able to predict with certainty the birth of a defective child.

In certain rare cases, this can be predicted through tapping the amniotic sac and developing a cell calture which is examined for chromosomal defects. Certain chromosomal defects such as mongolism may occur in one in three live births in cases where the mother or father is a carrier. In general, they may occur one in fifty times in cases of the older mother, and one in eight hundred times when the mother is of normal childbearing age.

Similarly, certain defects caused by genetic disorders can sometimes be predicted. Where the disorders are caused by recessive genes--i.e., the abnormalities are not apparent in the mother or father, but one of them is carrying genes which cause abnormality in the child--this can sometimes be predicted. In the case of certain recessive genes, there is a one-in-four chance of PKU (phenylketonuria) or certain degenerative diseases of the nervous system. In cases of sex-linked diseases such as hemophilia, prenatal determination of sex could help in detecting a potential victim.

In the case of some of the chromosomal and genetic disorders, it is possible, and it may become more possible, to minimize the damage through early detection, management of the diet of the pregnant woman, and, perhaps, chemotherapy. Some of these disorders have no effective treatment as yet. It is clear from the odds for a normal or defective child that abortion as an answer in all such cases where defect is held possible would destroy many more normal fetuses than damaged ones. It is also clear that it is preferable that such cases be prevented through contraception rather than abortion.

In the case of defect as a result of German measles (rubella), exact diagnosis that the mother did or did not have the disease during pregnancy can now be made through blood tests. This can resolve anxieties of those women who believe that they have been exposed to the disease, but are not sure whether or not they contracted it, or those who report symptoms which resemble rubella. In the 1964 rubella epidemic almost 90 percent of the women who caught the disease in the first three months of pregnancy produced babies that were damaged, although some only slightly. When the disease was contracted later in the pregnancy, the incidence of damage fell to 25 percent.

Yet just as the ability to detect rubella has gone up, so have the possibilities of eliminating it as a danger. There are now being conducted tests on antirubella vaccine, and medical experts expect that the German measles problem will be eliminated in the next few years. Other viral problems will, however, remain. Furthermore, some of the damage which is thought to occur during fetal development actually occurs from viral infections after birth, and drugs may control this in the future.

There have lately arisen questions whether some of the chemicals, such as LSD, which are now widely taken by young people in their late teens and early twenties, may cause chromosomal defects and abnormal children. This is currently subject to dispute among medical experts. The tragedies caused by the taking of thalidomide by pregnant women added to the pressures for permitting abortions in the case of a potentially defective child.

These are the medical facts about fetal defect before the doctors, but, as in the case of the biological facts, they only raise, not settle, the ethical questions. An argument can be made that since, with the exception of defects which are 10O percent predictable, aborting because of potential defect involves aborting a certain number of potentially normal children, abortion ought to be avoided as a solution. Some would argue that it makes more sense to wait until the child is born and have it killed if if is defective and the parents so desire. They say that this approach is consistent with the permissive nature of laws demanded by some people in favor of completely free personal choice by parents in regard to abortion. Whatever the logic of this, however, it is simply a fact that our society sees it as infanticide and murder and does not accept it as an alternative.

A second, and more long-range, ethical question is what to do about abortion of the potentially defective child in terms of the life it is likely to lead, or that all defective children are likely to lead. On the whole, our society has been practicing what one doctor terms the "social infanticide" of retarded children by care in grossly inadequate institutions, where death occurs far earlier than it should.

We are, however, beginning to bring the matter of retardation out in the open, and to find ways of helping the retarded to live more fruitful lives. Is there, therefore, as much reason, for the sake of the mother or the child, for aborting the potentially retarded as there used to be? If we broaden the laws to permit abortion of the potentially retarded are we likely to be as concerned with providing those born retarded with a better life? How fair is it, on the other hand, for society to force a retarded child on parents who would prefer that it not be born? The decisions involved here would be a great deal easier if more help were provided to prevent financial and social catastrophe from the birth of a totally disabled child. Many doctors think that this is the direction we should take, and that our research must continue to be directed at saving and improving life rather than taking it away.

The Psychiatrist's Variables

While the number of therapeutic abortions performed in this country has declined for several years, the relative number of those granted for psychiatric reasons has increased. In the process, psychiatrists have come under some criticism for being nonscientific" in their judgments about whether an abortion as warranted. Yet psychiatry can only be more anecdotal and empirical than scientific; judgments can only be based on an accumulation of data, rather than on precise cause-and-effect analyses. Moreover, much of what the psychiatrist is called upon to say is in the order of prediction of future events rather than diagnosis of present disease. The problem is that the psychiatrist is considering not only specific psychiatric illnesses, but more vaguely defined concepts of "mental health" as well.

Therefore, no generally accepted psychiatric criteria for abortion have been established as yet. The reaction of psychiatrists to the problem ranges from rejection of any justification for abortion to great permissiveness. As Dr. Joseph C. Rheingold of the Harvard Medical School's Department of Psychiatry has written:
    The explanation of the inconsistency of attitude [on the part of psychiatrists] lies both in the psychiatrist himself and in the complexity of the situations under judgment. Apart from his religious convictions, the psychiatrist is influenced by his ethical and philosophical leanings, his social values, his professional associations and the abortion "taboo" among physicans, the pressures put upon him, and his unconscious dispositions. The methodological approach, too, is variable... The psychiatrist may or may not take into account humanitarian factors, the socioeconomic situation, the woman's significant relationships, eugenic possibilities, and the quality of prospective motherhood. He may conform to the letter of the law, he may allow himself a very liberal interpretation of it, or, in good faith, he may use subterfuge to bring his findings into consonance with the law... He may err in either direction: the woman may be aborted, with regrettable consequences, or she may not be aborted, with regrettable consequences.
Thus, a psychiatrist makes his decision based on a combination of a codified body of knowledge, the facts of the individual case, and his own clinical judgment.

An abortion may or may not relieve a mental problem troubling the pregnant woman. The desire for an abortion may itself be seen as a symptom of other problems, or may be seen as a sign of health-a facing up to the problems involved in having the child. Some psychiatrists would argue strongly that a pregnant woman can be forced to go ahead with the pregnancy, but she cannot be forced to be an adequate mother.

The inherent imprecision of the psychiatrist's indices leads some to say that since so little is known there ought to be minimal permission for abortion on the grounds of mental health; it leads others to say that if a woman says that she does not want the child, that ought to be reason enough for granting an abortion, and that there ought to be broad legal pemission for this; still others says that the law ought to withdraw, leaving the question of abortion to the mother's private decision, reached with the help of professional advice.

The Doctors and the Law

What all of this shows is that doctors are far from uniform in their approach to abortion. Medical practitioners in the United States are a heterogeneous group, more so, perhaps, than in many other countries. It is this, in fact, which leads to variations in the ways that the existing laws are applied, so as to permit, or not permit, abortions under similar circumstances. There are variations among individual doctors, among hospitals, and even among the medical communities of different cities. Nevertheless many, perhaps most, physicians believe that abortions should not be treated as strictly a medical matter, like appendectomies, subject only to decisions by doctors and patients; they believe that society, through the law, should have a voice. One thing that doctors quite naturally agree on is that they prefer that women receive medically safe abortions from licensed physicians than from unqualified, illegal abortionists. Yet, under the current legal situation, it is simply a fact that many thousands of women resort to the illegal abortionists.

The question, then, is: What should the abortion laws say? As might be expected, there is a wide range of opinion among physicians, as there is among the public at large. At either pole are those who prefer that the laws stay as they are and those who would permit, in effect, abortion at the request of the mother. Some who feel that the laws should stay as they are believe that the new concepts of "health" are still too nebulous to base widespread permission of abortion on them. They argue that we should know more about the possible effects of changes in the law before we proceed to make them. Some would prefer a law which permitted abortions to protect the life and health of the mother, some giving this a narrow and some giving it a broad interpretation. Some doctors would prefer that the law did not specify rape, incest, and fetal defect, and that these indications be subsumed under the general category of deciding whether the health of the mother, induding her mental health, would be impaired. Among the reasons for this is that it would elIminate the problem of proving rape or incest before an abortion could be approved, and it would not appear to specifically condone abortion in case of potential defect. Some physicians who would prefer wider legal perrnission for abortion feel that the broader criteria should be spelled out. They argue that if the laws simply specify the life and health of the mother, in many areas through conservative interpretations the laws' effects would be the same as they are now. Therefore, they urge that the law should specify more than life and health, perhaps the indications specified in the American Law Institute proposal. Some are concerned that the ALI proposals do not cover many, perhaps most, of the situations in which women now seek abortions and they therefore would add a provision, similar to those in the Scandinavian or new British laws, taking account of the mother's general well-being, or the total circumstances of her life. Some doctors would argue that more lenient abortion laws would give a better opportunity, as the Scandinavian laws were designed to give, for helping to solve the larger problems of women who seek abortions. As Dr. Duncan E. Reid, President of the American College of Obstetricians and Gynecologists, and Professor of Obstetrics and Gynecology at Harvard Medical School said:
    What I am proposing is that this addition [provision for taking account of the woman's total environment, present and future] be made to our law so that the medical profession can no longer disregard its duty in counseling. In our hospital, let it be said that if we do therapeutic abortions, and we do, we do more on the ward service than we do on private patients. I want this addition to the law so that we can counsel these women. It is up to us as a profession and also the social-service workers of this country to realize that we must act in concert and regulate pregnancy before this situation develops.
Along with this, it is suggested, there should be a clause, similar to the one in the British law, which specifically exempts the doctor who has a conscientious objection to abortion, or simply takes a more conservative view of it, from prosecution for not performing one.

Chapter 8-The Ethicist's Perspective