Sunday, April 15, 2012

Governor Brewer Practices (Bad) Medicine

We have Big Invasive Government here in the wild west. Arizona Governor Jan Brewer took time from wagging her finger at black men to sign the nation's most restrictive anti-abortion legislation last week. The bill contains the boilerplate provisions present in other states' recent legislation, such as 24-hour required ultrasounds, counseling, showing pictures of developing embryos, etc, but the Arizona bill goes further. 

1. The most remarkable thing is that Arizona's bill prohibits all abortion after 20 weeks gestation even in cases of lethal fetal anomalies, unless the mother's health is imperiled by a "medical emergency". The woman is required by law to carry the pregnancy until...when? Presumably until natural labor starts or in utero death occurs.  Brewer's rationale is that:

“Knowing that abortions become riskier the later they are performed in pregnancy, it only makes sense to prohibit these procedures past twenty weeks."

She's practicing medicine, plain and simple... and it's substandard medicine at that.  The question is not whether abortion is safer at 11 weeks versus 20 weeks gestation-- there is no question that earlier terminations are safer and more cost-effective-- rather, the question is whether carrying a lethally anomalous fetus to term or until fetal death is safer than termination at 20 or 22 weeks: the answer is almost universally that early termination is safer.  

Lethal fetal anomalies are rarely diagnosed before 18 weeks and sometimes much later; this bill will certainly increase the use of 16-17 week ultrasound to look for gross anomalies (anencephaly and renal agenesis) in order to plan possible termination before the 20 week legal deadline. And since such early fetal anatomy is not adequately developed to see more subtle structures such as heart valves, etc, a subsequent ultrasound will be likely recommended in most pregnancies. Brewer's bill will cost more money for everyone since the current practice is to get one screening ultrasound around 20 weeks which can visualize major and minor anomalies.

There will be further increase in the cost for health care and maternal risk when anomalies are found after 20 weeks since the pregnancy will need to be carried to fetal death or natural onset of labor, with greater occurrence of morbidity, pain, c-section, gestational diabetes, pre-eclampsia, etc, etc, as the gestational age increases.

These patient-doctor decisions are always gut-wrenching; the presence of the Arizona legislature and Governor Brewer in this discussion is unnecessary and intrusive and will not decrease the number of abortions.

2. But there's even more crappy medical reasoning in the bill.  It also limits medical abortion before 9 weeks which is noninvasive and safe and quickly becoming the standard of care for 1st trimester termination.  This is when most abortions take place...and when Doctor Governor Brewer says they are safer.  The Arizona prohibition is inexplicably limited to medical abortion (ie, not suction) prescribed more than 30 miles from a hospital with the implied intention of patient safety.  In practice, however, this rule serves as an unnecessary (and dangerous) barrier to abortion services.  Failed medical abortion occurs at a statistically low rate and these failures are easily diagnosed with office ultrasound and completed with office suction; a hospital is not necessary.

The likely consequence of both of these measures within the bill is that pregnancy care in both instances will become more expensive, with greater opportunity for mismanagement and greater health risk to women. 

My Comment 1:  I get it. Conservatives don't like abortion. Newsflash: nobody does. Arizona is ignoring evidence-based medicine, requiring reckless practices, subverting the doctor-patient relationship, increasing bureaucratic hassle and putting women at risk.  This bill only serves to increase barriers to safe and effective pregnancy care and will likely not reduce abortion rates at all. The implicit rationale in the bill is to badger women and the result will be to require medical personnel to practice substandard medicine.  Is this really where we want to go as a state?

A better approach might be to define the purpose of the legislation and then look to other locales that have succeeded in this purpose.  If the desired goal is to reduce abortion, then look to other states and other nations with low abortion rates to see how they have done it.  Western Europe and the Northeast United States have the lowest abortion rates in the world and they've achieved this without draconian invasion into the doctor-patient relationship but rather increased access to contraception and education.

If the desired purpose is to eliminate all abortion, then Governor Brewer and the Arizona legislature should run for election in Fantasyland and and preside over a mythical population.

My Comment 2: Make no mistake, the Arizona bill is invasive.  It extends authority of the state into the most intimate decisions a woman can make.  Small-government conservatives should be bothered by this authoritarianism since Governor Brewer can glibly mischaracterize 'safe medicine'  while signing a bill that severely restricts medical decision-making and eschews science.  And Republican state legislator Kimberly Yee says: 

“The state has a compelling interest to protect women from the serious health and safety risks of abortion."

If the State of Arizona is in the business of deciding the absolute and relative safety of medical and surgical interventions then why not outlaw breast augmentation, botox, Viagra, and just about every aesthetic procedure... which all surely carry more risk than non-intervention?  

This belies the real purpose of Arizona's abortion bill: to hassle women into making a decision pre-ordained by the state.  Implicit in this bill is the opinion that Governor Brewer and the Arizona legislature know better than you or your doctor the optimal management of your pregnancy.

My Comment 3: Elections matter and the passage of this bill is the result of the election of conservative lawmakers who apparently reflect the will of the people, and the trend seems to be toward even more social conservatism and intrusion into people's private lives.  The unintended consequences of this approach are legion.   Instead of decreasing abortion these measures will merely increase risk-taking and unsafe practices.

My challenge to lawmakers:  If the people of Arizona truly believe that personhood begins at conception, and you truly want to legally protect all embryos then pass a law that states as much. This is the intellectually honest approach to outlawing abortion: if the fetus is a person then make that law, otherwise shut up.  For the Governor to engage in mental masturbation about what is "safe medicine" and to pass inane requirements prohibiting the standard of medical care do nothing to reduce abortion or advance the discussion. 

1 comment:

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