Wednesday, January 19, 2005

Abortion: What's the Goal?

A previous president once said that abortion should be safe, legal and rare. While the first two may not be universal goals, the third can be considered the holy grail of both sides of the abortion debate. The goal should be to reduce the numbers of abortions.

Halifax (name withheld on the internet) has opined that Bush will be forgiven by pro-lifers on his “nonchalance” regarding gay marriage and abortion because he has passed the partial birth abortion (PBA) ban and the Unborn Victims of Crime Law. Granted, pro-lifers most likely view these two items as significant, but I will argue contrarily. And I will not argue because I want more third trimester abortions, nor because I feel that crime against pregnant women should go unpunished. I will argue that these two items are poor legislation because they will not reduce the number of abortions, nor will they reduce the crime against pregnant women. The goals are lost amidst emotional rancor that panders to the socially conservative base, and the women and children will be the losers. Solutions are found in a pragmatic, multifaceted approach that would improve quality of life for the most vulnerable members of our society with education and access to health care.

First, a few truisms. Number one, abortion is here is here to stay. Since time immemorial women have attempted to terminate their pregnancies and this trend will continue regardless of any legislation humans might pass. Especially with the advent of pharmacologic agents that have made abortion more private, more safe and more accessible. If outlawed, abortifacient agents—RU486, methotrexate and cytotec-- would still be available on the gray and black markets. The desire for some women to terminate their pregnancy is strong enough that the demand will be met by supply regardless of any attempt to limit it. Even if every other state would outlaw abortion, right or wrong, the surreptitious leakage of these medications across state borders would surely commence.

Number two, fetuses are not children, and under the law, fetuses do not have personhood rights. I am not a lawyer, and this may seem like a technicality, but it’s true nonetheless. In the McCorvey opinion of a few years ago offered by Halifax , the judge refers to a fetus as a "child", which is at best a sloppy use of the legal language of the time, and at worst, an emotional plea that belies her prejudice under the law. The Unborn Victims Law of 2004 attempts to give more value to the fetus, and even calls fetuses "children", the legality of which will most likely be argued in the courts in due time before anybody serves time for “murdering” a fetus. Regardless, such legislation as written will not prevent one abortion, nor will it likely reduce violence against women, which to my knowledge is already illegal. (In 2002, the Bush administration attempted to give personhood rights under executive regulation for the State Children’s Health Program (SCHIP), but of course, overstepped reason by not only trying to define “childhood” as beginning with conception, but did so without legislative support.) Call me cynical, but that’s the way I see it. I’m pretty sure you could see strong support for giving, say, 32 week fetuses certain (albeit very restricted) rights under the law that no legislator would or could oppose, but even then, the impact on protection of fetal life would be negligible since terminations at such an age are exceedingly rare and universally for good reason.

Number three, the partial birth abortion ban is a sham. The term itself is not found in the medical literature. The law as written only prohibits one very specific form of the procedure that is described as delivering a live fetus in breech position and then opening and collapsing the skull for delivery. Apparently, a similar procedure would be legal as long as the fetus is rendered lifeless beforehand by some other means, say, umbilical artery potassium injection (or conceivably, electric shock or purposeful blunt trauma.) This law is just plain stupid, and acts to limit the woman’s and physician’s choices while not materially changing the outcome for the better. The majority of third trimester abortions are for severe fetal anomalies, severe maternal medical disease, or both. Of the 1.3 million abortions in the US every year, those after 21 weeks make up less than 1% . Forcing these women to undergo an invasive umbilical artery catheterization prior to the termination may increase her risk; therefore, those exact women who would most benefit from a late trimester abortion are thus put at greater risk because they cannot undergo the very safest procedure. The federal government, under President Bush, has now attempted to enter the medical decision-making field. (Mr. Bush’s decisions regarding pre-emptively invading countries is bad enough, let’s leave him out of the doctor’s office.) As had been predicted by Clinton, the PBA ban has been found unconstitutional because of the lack of provision for the well-being of the mother. (Stenberg v. Carhart, 2000) So, Halifax, what good is a law if it is innately flawed and found unconstitutional, other than to stir up the pro-lifers in time for election?

Number four, abstinence-only programs are educational malpractice. In a perfect world, all sexual intercourse would occur between consenting adults with adequate social and family support. Such support would necessarily include health insurance, access to prenatal care and contraception, with a lack of threats to one’s personal well-being. Unwanted pregnancies would be avoided by the proper instruction in the use of birth control. Unfortunately, the perfect world doesn’t exist. Teen-agers have sex. They have sex with for a myriad of reasons, under a plethora of circumstances, with an uncountable number of partners. Statistically, the majority of US teens will engage in premarital sexual activity by age 20. Haranguing about celibacy does not change this statistic—90% of those “choosing” abstinence-only will eventually fall to the siren of illicit sex; only now they do so without knowledge of contraception and STD prevention, thus leaving them more vulnerable. According to Planned Parenthood (with multiple supporting references): “When they do become sexually active, though, they often fail to use condoms or other contraceptives. Meanwhile, students in comprehensive sexuality education classes do not engage in sexual activity more often or earlier, but do use contraception and practice safer sex more consistently when they become sexually active.” Without birth control, 85% of sexually active women will become pregnant within a year. Therefore, the public health dictates that sex education and birth control should be available to all people who require it (which is ALL women and men BEFORE they become sexually active.) As long as we as a society deny this fact, we will live in a world of unwanted pregnancy and preventable abortion. Addressing this most vulnerable segment of the population, we can work on the highest proportion of young women who choose abortion, thereby getting the greatest benefit. Not only do we avoid the loss of an unwanted fetus, we save the young woman the anguish of having to face such a heartbreaking decision, which the real lesson of McCorvey has shown can lead to lifelong distress.

The solution: If the goal is to decrease the number of abortions, then common sense would dictate that we should address social factors associated with abortion. According to Alan Guttmacher Institute, of the 1.3 million abortions, almost 90% occur in the first trimester, almost all of which are unwanted pregnancies (see “agi-usa” reference above.) Over half are in young women (under 25 years old) with the largest proportion among 18-19 years old (19%). Regrettably, the US has the highest abortion rate in the developed, western world. As Huf would remind me, causality for any phenomenon, especially abortion, is hard to generalize, but we do see strong associations worldwide; and more importantly, negative associations.

For example, some of the highest rates are in countries where abortion is illegal, namely Latin America, thus showing us that simple prohibitions are not satisfactory; and the lowest rates are in countries with very liberal laws, namely Northern and Western Europe. The strongest associations are that abortion rates are lowest in nations where women are empowered financially, health insurance is guaranteed and government-run quality sex education is either mandatory or strongly recommended in the early teen years.

Even in that minority of instances where women are married prior to first sexual experience, quality sex education and access to healthcare would still be empowering. By linking health insurance to employment or spousal support, women are left vulnerable to the whims of their husband or their employer. This arrangement has the potential effect of decreasing their access to birth control or prenatal care, thus increasing the likelihood that abortion would become a choice for that woman or couple. Furthermore, pro-life groups fight access to morning-after pill which has been implicated in decreasing the number of abortions by tens of thousands per year in the US (see “womanissues” reference above.)

Planned Parenthood has been much maligned by many pro-life activists because they are the largest single provider of pregnancy terminations in the US. The fact that is lost is that PP is also the number one single entity working to prevent abortion—with education and affordable and accessible birth control. In effect, PP is performing the function that public health departments and secondary schools perform in other civilized nations. As a society, we should be ashamed at the abysmal state of our national health that we must rely on a philanthropic organization to be the primary purveyor of such an important and necessary function.

While the Bush administration and pro-life groups dance around the periphery of the abortion debate, and try to appeal to the lowest emotional level, we continue in our national health nightmare. Our president accepts kudos by his misguided political base because he supports worthless laws, such as PBA ban, and ridiculous policies, like abstinence-only education and “life begins at conception.” Meanwhile, American children live in ignorance and deprivation and get pregnant prematurely. Ironically, many of these same adults who gush about the virtues of the PBA ban and abstinence-only education also protest the very things that would likely lead to fewer abortions because of some ideological aversion to big government, or national health, or federal deficits, or whatever. We argue endlessly about allocating a few hundred million dollars to reduce abortion—a yearly budget that would be equal to a couple weeks’ expenditure for our Iraqi occupation. I maintain that for a president, and other leaders, to stoke the flames of controversy with talk of abstinence-only and partial-birth abortion, etc. is to act immorally, and with forethought. Mr. Bush should know better. A true leader would use his Ivy League education to interpret the data, and present the cold hard facts to his loyal constituency. Until he does that, the blood of every preventable abortion is on his hands.

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