Allan Rosenfield, Sara Iden, Anne Drapkin Lyerly. Bioethics. Editor: Bruce Jennings, 4th Edition, Volume 1, Macmillan Reference USA, 2014.
Medical information and perspectives on abortion are not just data untinged by values. Throughout history, medical facts and moral values regarding abortion have been inextricably intertwined. People interested in the ethics of abortion turn to medicine and medical practitioners for the following information and perspectives:
- Whether medical knowledge clarifies the moral status of the fetus as a human being;
- Whether medical information on abortion confirms it to be safe for the woman;
- What the medical perspectives are on performing early versus late abortions, particularly in light of controversies regarding partial birth abortion;
- what the public health and international perspectives are on abortion.
Medical Knowledge Regarding Status of the Fetus
However much information biomedical investigation may provide regarding pregnancy, fetal development, and abortion, it cannot provide a determination as to when human life begins. The answer to that question—which deals with the moral status of the fetus—is arrived at by a process that entwines medical facts with experiences, values, religious and philosophical beliefs and attitudes, perceptions of meaning, and moral argument. Such a process extends beyond the special competency of medicine. For example, when ensoulment—an ancient criterion involving the infusion of the soul into the body of the fetus, thus conferring moral status on the fetus—occurs, medicine has never had the ability to establish. Similarly, some physicians disagree about the moral status of the fetus and the permissibility of abortion.
There is confusion about the definition of abortion. Spontaneous abortion, or what is commonly termed a miscarriage, refers to a spontaneous loss of a pregnancy before viability (at about twenty-four weeks of gestation). Losses after that point in a pregnancy are termed preterm deliveries or, in the case of the delivery of a fetus who has already died, stillbirths. The terminology commonly used in relation to induced abortion is different. Viability is not the key point; rather, any termination of a pregnancy by medical or surgical means is termed abortion, regardless of the stage of the pregnancy.
Safety and Harm of the Woman
There is a close tie between medical information regarding the safety of abortion practices and ethical positions on abortion. For example, at a time when abortions were frequently harmful to women—such as when legal restrictions increased recourse to untrained practitioners—opponents of abortion appealed to information on the likelihood of medical harm to the woman and risks of future pregnancies as arguments against abortion (Kunins and Rosenfield 1991). As of 2003, induced abortions performed within the first twelve weeks of pregnancy are among the safest and simplest forms of surgery. Maternal mortality ratios (number of deaths per 100,000 live births) show that both first- and second-trimester abortions performed by properly trained personnel are safer in general than carrying a pregnancy to term (Cates and Grimes 1981). As a result, ethical arguments against abortion tend to be restricted to areas other than maternal safety. Nonetheless, some aspects of medical safety and harm—including possible complications and psychological sequelae—continue to be important for ethical discourse, especially because a basic tenet of medical ethics is to avoid harm.
Possible Physical Harm
The major immediate complications of induced abortion, in order of frequency, are infection, hemorrhage, uterine perforation, and anesthesia-related complications. Overall complication rates for legal firsttrimester abortions are less than 0.5 deaths per 100,000 abortions performed (compared with more than four per 100,000 in the early 1970s, before the US Supreme Court decision Roe v. Wade 410 U.S. 113 [1973]) permitted medically supervised abortions. Medical complications associated with induced abortion are directly related to gestational age and the type of procedure used to terminate the pregnancy. Most abortions (over 90%) in the United States are performed within the first twelve weeks of pregnancy, when abortion is safest. More serious complications may occur in procedures performed later in pregnancy.
Abortion Procedures
Information on abortion procedures often sheds light on questions of safety and on other aspects of abortion that are relevant to ethics. The most common early-trimester abortion procedure (between seven and twelve weeks’ gestation) is suction curettage, in which a thin plastic tube (cannula) is inserted through the cervix and the contents of the uterus are aspirated by negative pressure vacuum. After the aspiration procedure, curettage (performed with a sharp, spoon-shaped surgical instrument called a curette) is usually performed to ensure that all fetal tissue has been removed. Complications of suction curettage procedures are rare and even when they occur are usually not serious. Many physicians consider general anesthesia an unnecessary additional risk because injection of local anesthetic into the cervix usually is effective (Grimes et al. 1979). A short course of prophylactic antibiotics is sometimes prescribed, although postabortion infection is uncommon with suction curettage. Because of its safety, suction curettage is performed most often in free-standing clinics or outpatient centers in hospitals.
At twelve to twenty weeks’ gestation, the most common method used for abortion is dilation and evacuation (D&E). In this procedure a specially designed forceps is used in conjunction with vacuum aspiration to facilitate the removal of the uterine contents. Before the procedure, the cervix is dilated gradually over a number of hours by use of sponge-like materials that expand as they absorb local cervical fluids. Though still considered a minor surgical procedure, D&E is more involved and invasive than suction curettage, and a trained and skilled clinician is essential. Although it is possible to use only local anesthesia for D&E, the procedure is considerably more uncomfortable than suction curettage, and general anesthesia is often used, increasing risk. The D&E procedure can be performed in freestanding clinics, but often ambulatory surgical services in a hospital are chosen for procedures performed later in pregnancy (after the fourteenth week) because emergency care can be quickly provided in case of a complication. Informed consent procedures require discussion of the various methods of abortion and the anesthesia alternatives.
The other abortion procedure used fairly commonly in the second trimester is instillation abortion. In this procedure, instillation of a solution into the amniotic cavity through the abdomen via amniocentesis results in the death of the fetus and termination of the pregnancy. Uterine contractions signaling labor begin twelve to twenty-four hours later and culminate with the expulsion of the fetus. Anesthesia is not commonly used for instillation procedures. Discomfort varies widely among patients, usually in relation to the length of labor and the time before complete expulsion of the fetus and placenta. Serious complications can occur during instillation procedures, including inadvertent introduction of the solution into the mother’s bloodstream, excessive bleeding at the time of expulsion of the fetus, and retention of the placenta. For this reason hospital admission is usually advised. Instillation procedures are used mainly for procedures beyond the twentieth week of gestation. All late-pregnancy abortion procedures carry significant risk if performed by physicians not specially trained in the technique.
A promising alternative to surgical abortion for early first trimester terminations of pregnancy is chemical abortion. For example, the antiprogestin drug RU-486 stops the ovaries from producing progesterone, an essential hormone in the early stages of pregnancy and in implantation of the embryo. The drug is given within the first forty-nine days of a confirmed pregnancy and is used in conjunction with a prostaglandin, which produces uterine contractions and subsequent expulsion of the uterine contents. A follow-up visit is necessary eight to twelve days later to ensure that complete termination of the pregnancy has occurred.
On September 28, 2000, the US Food and Drug Administration (FDA) approved RU-486 for use in the United States. It has been distributed since November 2000 by Danco Laboratories, LLC, under the brand name Mifeprex (generic name, mifepristone). According to the FDA guidelines, the drug has been distributed only to physicians and is not available through pharmacies. Furthermore, the FDA has approved a specific regimen for the use of RU-486. Three office visits are necessary: the first for the physician to make the diagnosis and to administer the RU-486; the second, two days later, for the prostaglandin; and the third within two weeks for the final follow-up. In France, a fourth visit is required by law because a one-week delay between the diagnosis of pregnancy and the initiation of an abortion procedure is mandated. Due to the requirement of three visits (or four in France), the fact that there may be a few days before the abortion occurs and as many as ten or more days of vaginal bleeding thereafter, and because medical abortion may be more expensive than surgical abortion, many women in France and the United States prefer suction curettage (Kolata 2002). However, there is anticipation that as awareness grows, many women will prefer a medical means of abortion, not wishing to undergo surgery (albeit a minor procedure) or to be subjected to the harassment that may occur outside some facilities.
Successful termination has been found to occur in 97 percent of patients using the RU-486 regimen. The other patients need suction curettage for complete removal of the products of conception. In comparison, for surgical procedures, less than 1 percent of patients require a second curettage, in the event that the procedure was incomplete. Most women experience strong cramping after taking the prostaglandin (because the drug induces uterine contractions) and usually expel the products of conception within a few hours after receiving the prostaglandin. In France, RU-486 is therefore provided only through clinics, and the abortion often occurs during the four hours women remain in the clinic after taking the prostaglandin. However, some French physicians believe that a clinic setting is not essential.
In the United States, specific requirements for facilities providing abortion vary from state to state. Federal guidelines, however, require only that RU-486 be prescribed by or under the supervision of a physician who can diagnose the duration of pregnancy accurately, diagnose an ectopic pregnancy, and either can provide surgical intervention in cases of incomplete abortion or make arrangements to provide such care through others.
Although studies have shown the safety and effectiveness of RU-486 as a morning-after pill for use after unexpected midcycle intercourse (Ashok, Wagaarachchi, Flett, and Templeton 2001), preparations containing the hormones found in oral contraceptive pills (estrogen and progestin or progestin alone) have been approved for this purpose. Furthermore, the copper-T intrauterine device (IUD) can be inserted up to five days after unprotected intercourse to prevent pregnancy. Both emergency contraceptive pills and the IUD are readily available and remain the standard of care for postcoital contraception in the United States (American College of Obstetricians and Gynecologists [ACOG] 2001).
Availability of Abortion Providers
Obstetrician-gynecologists perform the majority of abortion procedures in the United States. Other providers, such as family practice physicians, midwives, and nurse practitioners perform a small percentage. There are serious concerns about the provision of abortion procedures in the future for several reasons. Although most obstetrician-gynecologists believe that women should have the right to choose to terminate a pregnancy, at the same time, most do not wish to perform abortions. As a result, approximately 84 percent of counties in the United States do not have an abortion facility, and the number rises to 94 percent outside metropolitan areas.
Many obstetric-gynecologic residency training programs do not offer abortion training routinely, and as a result, many graduating residents have little or no training in this area. However, there has been an increase in the number of residency programs providing training in abortion procedures. In 1996 the Accreditation Council for Graduate Medical Education required obstetric-gynecologic residency programs to include family planning and abortion training for its students, though abortion was generally still presented as an elective rather than a routine part of training. The impact of these requirements was demonstrated in a survey conducted for the National Abortion Federation. The investigators found that from 1992 to 1998, the proportion of obstetric-gynecologic residency programs that reported providing routine training in first trimester abortion increased from 12 percent to 46 percent and that routine training in second-trimester abortion increased from 7 percent to 44 percent (Almeling, Tews, and Dudley 2000).
Even where training has taken place, the increasing incidence of harassment and even violence (including the 1993 and 1994 murders of abortion providers in Florida) has resulted in more reluctance on the part of physicians to be involved in the provision of abortion. In response to the escalating violence, Congress in 1994 enacted the Freedom of Access to Clinic Entrances Act. This statute established federal criminal penalties and civil remedies for violent, obstructionist, or damaging conduct affecting reproductive health care providers and recipients. The statute also supplemented the penalties available under then-existing federal criminal statutes such as the Hobbs Act, the Travel Act, and federal arson and firearms statutes. Rising violence and the federal response highlight serious ethical questions as to the social responsibility of professionals in this field to make certain that this procedure is available to all patients.
Possibly Harmful Effects on Subsequent Pregnancies
Questions have been raised about possible long-term harmful effects of induced abortion, especially for women who have had multiple abortions. Much of the concern centers on subsequent pregnancies, following one or more induced abortions. Medical evidence has consistently shown that a woman who has one properly performed induced abortion in the first trimester of pregnancy has the same chance of a normal outcome of a subsequent pregnancy as a woman who has never had an abortion. The evidence is less definitive for women who have had more than one induced abortion or an abortion with complications, although there is no reason to believe that additional abortion procedures, carried out by well-trained professionals will have a long-term adverse effect. Overall, in terms of medical risk, abortion procedures, particularly those carried out in the first trimester of pregnancy, are among the safest of all surgical procedures.
Psychological Effects
A much grayer area is the psychological consequences of induced abortion. It is difficult to generalize about the emotional responses of patients to pregnancy termination, but like physical complications, psychological complications may be related to the type of procedure and the gestational age at the time of termination, with earlier suction curettage theoretically leading to fewer psychological complications than later procedures. However, most studies in this area suffer from methodological problems, including a lack of consensus about symptoms, inadequate study design, and lack of adequate follow-up. Furthermore, so-called post-abortion syndrome does not meet the American Psychiatric Association definition of trauma (Gold 1990).
Despite the many problems with most investigations, “the studies are consistent in their findings of relatively rare instance of negative responses after abortion and of decreases in psychological distress after abortion compared to before abortion” (Adler et al. 1990, 42). US Surgeon General C. Everett Koop (1916–2013), at the request of the White House, undertook a major assessment of the literature on this topic and concluded in a 1989 congressional hearing that “the data were insufficient … to support the premise that abortion does or does not produce a post-abortion syndrome and that emotional problems resulting from abortion are minuscule from a public health perspective” (House Human Resources and Intergovernmental Relations Subcommittee of the Committee on Governmental Operations 1989, 14). Given Koop’s personal opposition to abortion, the conclusions of his assessment are of particular importance.
Approximately 10 percent of induced abortions in the United States take place between twelve and twenty weeks of gestation, and less than 1 percent take place between twenty and twenty-four weeks. This means that more than 150,000 second-trimester procedures occur each year, a much larger number than in other developed nations where abortion is legal. Most would agree that decreases in the total numbers of abortions would be highly desirable, particularly decreases in second-trimester procedures. The most common reasons for these later procedures, particularly among younger teens, are indecision about termination and the failure to recognize pregnancy (or being in denial regarding pregnancy). A smaller percentage of these later abortions occur for medical or genetic reasons, which theoretically may correlate with greater psychological distress.
Although techniques such as nuchal translucency measurement with serum screening, chorionic villus sampling, and early amniocentesis have allowed earlier diagnosis, the results of more commonly used techniques of antenatal fetal diagnosis with midtrimester amniocentesis are generally not available until well into the second trimester. Choosing to terminate a pregnancy is a serious decision that is rarely made lightly. In addition to complete information about abortion procedure options, counseling should be made available to women faced with a decision about an unplanned pregnancy.
Early Versus Late Abortions: Controversies in Medicine
Medical attitudes toward abortion have constantly been shaped by medical professionals’ knowledge of and attitude toward the stage of development of the fetus and its interaction with local cultural, religious, and legal ideas and beliefs. Together these factors have had great impact on medical practice. Medical practitioners often have more difficulty with late abortions than earlier ones because late abortion procedures are more difficult to perform because of the more advanced state of fetal development and because of the political climate surrounding so-called partial-birth abortion.
Before the latter half of the nineteenth century, abortions were available in the United States under the doctrines of British common law that permitted termination of a pregnancy until the time of quickening (detection of fetal movement). However, medical knowledge available at that time made it difficult to confirm a pregnancy with certainty before quickening, for it was only this detection of fetal movement that confirmed the existence of a living human fetus. Little in the historical literature describes how physicians in that era actually felt about abortions, although on the basis of the information that follows, one can assume that there were concerns about abortion.
By the second half of the nineteenth century, as scientific knowledge grew, so did the realization that fetal development occurs on a continuum, suggesting that the fetus is a living entity before fetal movement is felt. Prompted by this new medical knowledge, physicians, particularly those who were members of the newly formed American Medical Association (AMA), began openly to oppose abortion and urged its criminalization as an immoral practice. As a basis for this change, the Hippocratic oath was used to oppose abortion at any time during pregnancy.
The concept of the fetus as a human entity separate from the mother has long been the subject of ethical concern within the medical profession. The AMA principles of medical ethics permit physicians to perform abortions, provided the procedure is done in accordance both with the law and with good medical practice (Council on Ethical and Judicial Affairs 1994). In general, since the early twentieth century, especially since the US Supreme Court decision Roe v. Wade greatly liberalized the legal permissibility of abortion, medical practitioners have tended to place the value of the life of the mother above that of the fetus. There also has been general agreement that late abortion is permissible in cases in which medical judgment deems that the health of the mother is seriously compromised by a pregnancy. However, just as Roe v. Wade allowed for some restrictions on abortions after fetal viability, the medical profession has shown a reluctance to perform abortions later in pregnancy, even early in the second trimester.
In addition to facing ethical dilemmas over fetal and maternal rights, many medical professionals remain ambivalent about the morality of abortion, a conflict that is heightened both by increased technological sophistication in the field of perinatology and genetics and the political climate. Depending on the technology available to a physician and the condition of the individual fetus (gestational age and any developmental deformity), it is often possible, depending on the availability of neonatal intensive care support, to save the lives of premature babies born at twenty-seven weeks’ gestation. Babies born at twenty-four to twenty-six weeks and earlier have survived with intensive neonatal intervention and support, though often with some degree of functional impairment. With abortions occasionally performed up to twenty-four weeks’ gestation, one can see the conflict within medicine: fetuses that might be aborted by one group of physicians are aggressively supported as patients by another group.
Physicians who provide abortion services prefer to perform early abortions, that is, up to twelve weeks, for several reasons. First, it is generally agreed that though a fetus may exhibit primitive reflexes before twenty weeks’ gestation, there is no evidence that the brain and neurological system are developed enough even at twenty-four weeks for the fetus to experience pain. Second, second-trimester techniques that might appear to be more humane or to show more respect for the fetus generally entail more danger for the woman. Third, the physicians who are committed to offering abortion procedures are intent on offering the safest procedures for the woman and regard the benefit to the woman as superseding the goal of minimizing harm to the fetus.
The debate over partial-birth abortion has presented challenges to physicians, other providers of abortion services, and proponents of a woman’s right to choose to terminate a pregnancy. Legislation to ban this procedure has been proposed and debated in the US Congress, in several state legislatures, and in the US Supreme Court. However, these bans have not been constitutionally upheld because of the vagueness of the definition of partial-birth abortion (which is not a term used by medical professionals), the failure to allow physicians to protect a woman’s health after a fetus becomes viable, and the application of the ban before fetal viability (Annas 1998). In March 1995, the first Partial-Birth Abortion Ban Act (HR 1833, 112th Congress) was introduced in the US Congress to make it a federal crime to perform “an abortion in which the person performing the abortion partially vaginally delivers a living fetus before killing the fetus and completing the delivery.” In April 1996 President Bill Clinton vetoed the bill because of its failure to include an exception allowing the procedure to prevent serious, adverse health consequences to the mother (Clinton 1996, 643–47). Clinton vetoed a revised bill in October 1997 for the same reason (Clinton 1997, 1545). Over the interim between the two bills, medical organizations took conflicting positions.
In contrast to the AMA, which endorsed the federal bill, the ACOG executive board urged the president to veto the bill. The executive board understood the term partial-birth abortion to describe a method members of the ACOG would understand as intact dilation and extraction (D&X), one method of terminating a pregnancy after sixteen weeks’ gestation and specifically involving the following (ACOG 1997, 2):
- Deliberate dilation of the cervix, usually over a sequence of days;
- Instrumental conversion of the fetus to a footling breech;
- Breech extraction of the body excepting the head; and
- Partial evacuation of the intracranial contents of the living fetus to effect vaginal delivery of a dead but otherwise intact fetus.
Although the committee could identify no specific circumstance in which this method would be the only option for preserving the health of the woman, it stated that “only the doctor, in consultation with the patient, based upon the woman’s particular circumstances can make this decision” (ACOG 1997, 3).
Similar laws have been passed in more than two dozen states and been found unconstitutional. The most significant decision was issued by the US Supreme Court in a challenge to Nebraska’s partial-birth abortion law in the case of Stenberg v. Carhart, 530 U.S. 914 in 2000 (Annas 2001). The case involved Leroy Carhart, a Nebraska physician who sued in federal court to have Nebraska’s law declared unconstitutional because it endangered women’s lives and was void because of its vagueness in that physicians could not know exactly what procedure was proscribed. Ultimately, the Supreme Court ruled on June 28, 2000, that the Nebraska law and all other laws banning partial-birth abortion were unconstitutional. The majority opinion held that the law was unconstitutional for two reasons. First, it did not provide an exception to protect the health of the woman as required by Roe v. Wade. Second, the law imposed an undue burden (as proscribed in Planned Parenthood of Southeastern Pennsyl-vania v. Casey 502 U.S. 1056 [1992]) because it was written so broadly as to ban not only the rarely used D&X procedures but also the D&E so commonly used to terminate pregnancies even early in the second trimester. Ultimately, the Stenberg v. Carhart decision reinforced the important position that women and their physicians should make the decisions regarding how abortions can most safely and satisfactorily be performed.
Public Health and International Perspectives
Abortion is widely available with varying restrictions throughout the industrialized world. There also has been a trend toward liberalization of abortion laws in many developing countries, such as in India, where abortion has been legalized, and in Bangladesh, where an early firsttrimester procedure called menstrual regulation (which is really an early suction curettage) has been officially sanctioned by the government even though abortion per se has not been legalized. Abortion laws are most restrictive in Latin America, sub-Saharan Africa, and Central Asia. Many of the countries in these regions have high rates of maternal mortality, and complications of illegal abortions are one of its leading causes. According to the World Health Organization, as many as 100,000 or more maternal deaths occur each year as a result of complications of unsafe, usually illegal, abortion. Even in the United States, some illegal abortions continue to be performed in cases in which women are without the resources to obtain a legal abortion.
Although reliable incidence data are lacking as to the number of illegal abortions performed worldwide, there clearly is a strong demand for abortion, a demand that will probably always exist. As evidenced by the estimated number of women who undergo illegal abortion, most women who are determined to terminate a pregnancy will attempt to do so either by themselves or with assistance. Consequently, the public health concerns about the complications of unsafe abortion, coupled with complex issues relating to the reproductive and autonomy rights of women versus the rights of the fetus, suggest the continuing importance that the field of bioethics must give to abortion, particularly the question whether and by what means abortion should be made available equally to all persons requesting it, regardless of national citizenship, ethnic or racial identity, or economic status.