Rickie Solinger. Feminist Studies. Volume 19, Issue 2, Summer 1993.
In the late 1950s, the obstetrical staffs of twenty-six hospitals in Los Angeles and the San Francisco Bay Area, responding to a questionnaire, evaluated a number of hypothetical abortion requests. Among them were these three cases:
Mrs. C. is a thirty-eighty-year-old woman who has had six children in the past ten years. At this time, she is two months pregnant and severely depressed. After an unhappy childhood and marriage, Mrs. C. sees herself as a failed mother, wife, and housekeeper.
Each of her recent pregnancies made Mrs. C. tired and depressed. During her last pregnancy one year ago, she spent most of the time in bed, vomiting a great deal, unable to eat; twice she was hospitalized for dehydration and weight loss. Following delivery, Mrs. C. was chronically depressed and listless, with multiple physical complaints. Presently, she complains of being tired, of not caring and says she wants to rest and sleep most of the time. She states that she can’t eat and that she vomits when she tries. She appears emaciated and hollow-eyed. Although she seems fairly well in contact with reality, she claims to be unable to face the prospect of a seventh pregnancy.
Mrs. A. is thirty-two. She has three healthy children, ages four, six, and seven. She is now seven weeks’ pregnant. There is conclusive evidence that she had an attack of rubella two weeks ago.
Miss C. is a fifteen-year-old daughter of a minister. Eight weeks ago she was raped by an escapee from a state institution for mental defectives and became pregnant. As a result, Miss C. is experiencing serious emotional distress.
Naturally, both the lawyers who devised the questionnaire and the physicians who responded to it were aware of Section 274 of the California Penal Code which “proscribe[d] as a felony the performance of an abortion upon a woman ‘unless the same is necessary to preserve her life.'” The lawyers and medical doctors were equally aware that in none of the three cases described above did the pregnancy directly endanger the life of the petitioner. A physician or a hospital agreeing to terminate any of these pregnancies would do so in violation of California law. The completed questionnaires were returned to professors Packer and Gampell of Stanford Law School and the results later published in the Stanford Law Review. The results indicated that almost one-half of the reporting obstetrical staffs were willing to break the law in cases where psychological or eugenic indications for abortion were present, or in the case of rape. A greater number, however, were unwilling. But even many of the unwilling physicians believed that almost any woman could arrange a legal, therapeutic abortion for herself if she shopped around among hospitals in Los Angeles or San Francisco. The Packer-Gampell questionnaire and numerous articles written by physicians and published in mainstream medical journals in the 1950s and 1960s reveal a profession deeply divided, embarrassed, angry, and frustrated over the issue.
This essay reviews discussion within the medical community in the postwar years concerning contraindications to pregnancy and the circumstances, if any, justifying therapeutic abortion. Such discussions reflect broader cultural attitudes toward women, mothers, babies, and pregnancy in the postwar era. They also illuminate the turmoil within the profession over these issues and the uneasy, insecure, but sometimes enduring, resolutions physicians devised to quell internal dissension and reinforce medical authority in the two decades immediately preceding Roe v. Wade.
Specifically, the essay argues that having been pushed into a defensive posture by the combination of medical advances, the specter of legal liability, and the emergence of women taking a new degree of initiative, physicians quickly transformed their uncomfortable defensiveness into an offensive posture toward women. To do so, they adapted a legalistic, tribunal method which tightened the association between two powerful professions-legal-izing medicine and medical-izing the law, at once.
In addition, many influential physicians in this era drastically redefined pregnancy in a direction prochoice advocates must still confront today. In the postwar decades, medical and psychiatric discourse uncoupled the woman and the fetus while, at the same time, binding women, in ever-tighter traces, to their pregnancies. These experts claimed that medical-technological advances removed all physical impediments to pregnancy. The advances could also reveal the fetus-as-homuculus. Pregnant females, in turn, became carriers and agents of protective custody. Many medical commentators in these years came to cast pregnancy first as a process of fulfillment and realization for the fetus. Still important, but now secondarily so, pregnancy was viewed as an essential expression of female identity and destiny.
This new approach to pregnancy, fetuses and pregnant women (although subordinated for a time to a discourse of women’s choice) has clearly provided the “scientific” underpinnings of the antichoice movement today. The postwar tribunal method of enforcing this perspective could be the state strategy of tomorrow. As we observe the dignity and protection of fertile women (embodied in Roe v. Wade) threatened in the early 1990s, it is well to consider the arguments and processes that experts used in our recent past to eliminate access to these rights. It is also worthwhile to consider that the strategies discussed here–as pervasively and powerfully promoted as they were–proved highly vulnerable to the grassroots counterclaim for choice.
Legal Abortions before Roe v. Wade
Dissension over abortion within the medical community was not a longstanding, intraprofessional problem. The post-Civil War state laws against abortion, which turned back the traditional right of girls and women to abort in the first trimester of pregnancy, stipulated that abortions were permissible only in cases where, due to a medical condition, the pregnant woman’s life was in danger. These new, late-nineteenth-century laws granted the determination to licensed physicians only. Through the late 1940s, legal abortions were performed often and routinely in most hospitals across the country. Medically approved contraindications to pregnancy included cardiovascular conditions (rheumatic heart, hypertensive-cardiovascular, coronary artery, and congenital heat disease); kidney dysfunction (chronic nephritis, hydronephrosis, polycystic kidneys, single kidney, renal stones, and pyelonephristis); neurologic diseases (epilepsy, multiple sclerosis, myasthenia gravis, and Meniere’s disease); toxemia; respiratory disease (tuberculosis, bronchiectasis); uterine disease (cancer of the cervix, fibroids); orthopedic problems, and blood diseases such as leukemia, ulcerative colitis, diabetes, premature separation of the placenta, otosclerosis, bowel obstruction, lupus, and thyrotoxicosis. Physicians occasionally performed abortions on women suffering from severe psychiatric disorders.
With such an extensive list of contraindications to pregnancy, abortion ratios at some hospitals were high in various decades before 1950, especially in comparison to what they would soon be, for example: 1 abortion to every 76 live births at Bellevue Hospital in New York; 1 to every 167 at New York Lying-In; and 1 to every 169 deliveries at Iowa University Hospital. Given the state of medical knowledge and the range of medical options, as well as prevailing ideas about the physical toll pregnancy took on women, non-Catholic physicians were often willing to sacrifice the pregnancy in favor of the well-being of the woman. Medical decisions concerning these matters were often predicated upon an assumption that pregnancy itself was a physical event or a medical condition which happened to girls and women, sometimes under conditions that were not physically or medically favorable. In these cases, it could be assumed that pregnancy could interact with and worsen a preexisting condition. A prominent obstetrician reminded his colleagues in 1958 that “for years medicine has taught that pregnancy, though a normal physiologic process, is such a tremendous burden that it adds an unbearable load to any ill, diseased, or handicapped person and, therefore, the two were not compatible.” This perspective assumed that the woman’s body was an integrated system which the pregnancy could undermine or disintegrate. The pregnancy itself might well take precedence over disease as the more destructive agent. Where contraindications existed, pregnancy–or the “unborn child”–was not granted precedence, or healing power, or constructed as a special condition virtually separate from the biological body or psychological mind of the impregnated female. The pregnancy was an additive, not an autonomous factor. By the twentieth century, girls and women in the United States had lost the traditional right to abortion by choice in the first trimester. But the newer association of law and medicine still sanctioned abortion under medically indicated, life-threatening conditions. In short, abortion served a function when pregnancy invaded and threatened a woman’s body.
A Professional Crisis
By the early postwar years, the medical consensus about the indications for abortion had fractured, and therapeutic abortion rates were plummeting in hospitals across the country. One authoritative study reported that the therapeutic abortion rate per 1,000 live births in the United States declined from 5.1 in 1943 to 2.9 in 1953, a 43 percent decline. A study of legal, hospital abortions in New York after the war demonstrated that the “overall frequency of therapeutic abortions declined by almost 50 percent.” Bellevue’s ratio was moving toward the 1:362 mark it would hit in 1965. Other studies showed that hospitals attached to the universities of Virginia and California which had ratios of 1:120 and 1:88, respectively, in the 1940s, reduced their rates by one-third to one-half over the next fifteen years.
The sharp decline in legal, therapeutic abortions performed in hospitals reflected the fact that by mid-century, mainstream medical opinion held that medical-technological and obstetrical advances obviated the need to interrupt pregnancy for most of the medical conditions previously considered incompatible with pregnancy. The same obstetrician who recalled the era when pregnancy was considered an “added burden, extra strain, and increased load” for ill or handicapped women in the recent past, pointed out that now obstetricians and their medical colleagues had access “to better understanding of such complications and a greater realization that with correct therapy the disease and pregnancy are compatible.”
Shared access to new technologies and treatments, however, did not mean that physicians shared a professional opinion about when and how these innovations should be applied. In fact, the new medical developments gave rise to a very complicated situation for physicians; the situation could be called a crisis which extended over a twenty-year period, at least.
The crisis derived, in part, from a profoundly paradoxical relationship between medical progress, the law, and politics. On the one hand, physicians were scientific and humanitarian heroes for subduing the role of pregnancy as an “added burden” and for devising methodologies to conquer diseases threatening to pregnancy and the pregnant female. On the other hand, state laws still required that the life of the pregnant women must be medically endangered to permit abortion. The legal system persisted in requiring a condition that the medical system said rarely existed. Consequently, legal demands were at odds with medical advances which claimed to have virtually removed the basis for medical judgments concerning indications for abortions.
Given their continuing legal relationship to abortion, however, and their interest in sustaining medical authority over pregnant women, physicians struggled to establish new bases for medical decision making. By the early 1950s, a number of physicians were airing these struggles before the medical community in the pages of the most prestigious medical journals in the United States. They described a bitterly contentious intraprofessional situation. The reports indicated that any sense of common purpose among physicians considering abortion had been severely undermined in the aftermath of medical advances. A 1952 article in the American Journal of Obstetrics and Gynecology referred to “considerable argument” and “this disunanimity of opinion” among physicians concerning the subject of indication for abortion. The next year, the Journal of the American Medical Association carried an article condemning the “confusion and uncertainty” surrounding this issue within the profession. Other articles chronicled specific disagreements among physicians and presciently despaired that a state of harmony could ever again be attained. Two Chicago physicians asserted that no agreement among medical doctors can “be achieved regarding either individual indications [for abortion] or general principles.” Another physician called his attempt to study the therapeutic abortion situation “a complete disaster” because “the categories of opinion were almost equal in number to the men concerned.”
Many physicians did not consider these open debates a sign of health within the profession. On the contrary, there is evidence that many felt that the new disunity over the abortion issue hurt the standing of physicians as expert, objective practitioners of medical science. Dissension also raised questions about the source and scope of medical authority. One physician observed, unhappily, that “if interruption of a pre-viable pregnancy is requested, the law at present dictates what medical opinion should be.” Another put the abortion issue and his professional discontent in a larger context of “restrictive efforts in every field of medicine. . . . Qualifications and regulations and boards are limiting the scope of the practice of individual physicians. Law now directs specific methods of treatment and prophylaxis for certain diseases.” Others expressed deep uneasiness that they were facing pressures to look beyond their traditional subject–the physical condition of the individual pregnant woman. They were being urged, inappropriately, to include social factors in their medical diagnoses.
The rise of psychiatric indications as grounds for abortion solved the issue of medical authority for many practitioners but deepened the uneasiness of many others not convinced in the 1950s that psychiatry belonged within the ranks of medical science. A Cleveland obstetrician identified his hospital’s biggest abortion problem as “those cases done for psychiatric indications, many times questionable psychiatric reasons.” Another obstetrician wrote that “medical men . . . have been able to markedly reduce the therapeutic abortion rate throughout the country only to find that this least justifiable of all indications, psychiatric reasons, has been allowed to run rampant.” A sociologist assessed the situation this way:
In recommending legal abortion, the psychiatrist faces the additional problem of hostility–or at least skepticism–on the part of the medical men who may be involved in ruling on his cases. Thus obstetricians may feel that psychiatric diagnoses are being used as subterfuges in instances where abortion is not really justified, and they are particularly unconvinced by assertions which the psychiatrist may feel [compelled to make] that the patient is likely to commit suicide if pregnancy is not terminated.
Many essayists in the medical journals were most concerned that the use of psychiatric findings in favor of abortion further undermined the traditions and the reputation of medicine as a scientific endeavor. Psychiatry was merely a “long practiced art,” at best “an infant science.” One physician referred to psychiatry and the application of its principles to the abortion decision as “a most nebulous, nonobjective, nonscientific approach to medicine” and pictured psychiatrists as engaged in “bedeviling” their colleagues to perform therapeutic abortions. Two California obstetricians argued that physicians who relied on psychiatrists to restore medical grounds for abortion and reestablish a justification for medical participation in the decision, felt their case weakened: “The extraordinary range of opinion represented among the psychiatrists is a far cry from the scientific objectivity that one hopes would apply to determinations affecting the life and health of patients.”
Disqualified as insufficiently scientific by many of these physicians, the psychiatrist could be identified as the “unwitting accomplice” in relation to abortion, a label with more legal than medical significance. Psychiatrists were portrayed in this way as pawns of importuning women, unlike real medical doctors who initiated any abortion decision in the interest of their passive, pregnant patients. One physician went a remarkable step further in associating psychiatrists with women who inappropriately initiated their own treatment.
In some parts of the country [criminal abortions] can be obtained so easily that when patients apply for a psychiatric consultation, for the purpose, so they state, of obtaining a psychiatric recommendation to the effect that their pregnancy be interrupted, the very fact that they make such an appointment seems to be almost presumptive proof that they do not wish the abortion, but rather psychiatric help in order to carry their child to term.
In the early postwar years, then, physicians struggled with the issue of abortion sans portmanteau. Many felt compelled to argue defensively for the obsolescence of medical indications while, at the same time, taking the offensive, arguing to sustain their professional prerogatives as abortion decisionmakers. Psychiatrists, alone, provided capacious medical grounds for abortion, but many practitioners rejected the terrain as polluted. Women, for three generations forced by law to submit to physicians as abortion decisionmakers, had now begun to initiate and pressure medical doctors to provide them with abortions, sometimes on whatever shifting grounds were approved at a given time and place. All physicians had to absorb the fallout that followed intramural dissension and undermined the united front of expertise. Similarly, all physicians involved in “therapeutic” abortion decisions had to adjust their personal, political, and professional judgments to the fact that the law and the law enforcement system were at least theoretically conditioning and monitoring their medical practice.
The Rise of Hospital Abortion Committees
By the mid-1950s, most non-Catholic hospitals had begun to address their vulnerability in relation to abortion by finding ways to reassert medical authority over the issue and to sustain physicians’ control over pregnant girls and women. Two strategies governed this process in a great many hospitals across the country. First, physicians recognized that they had to reassemble themselves as a collectivity from which professional expert diagnoses and decisions regarding individual women could be issued in one voice. In this setting, psychiatrists could be team players. They could bring their special perspective on the individual into the arena of experts and thus come to the aid of the profession while validating their own standing. Second, physicians redefined pregnancy in relation to women’s bodies in such a way as to efface the woman herself while giving precedence to the law and the fetus. Again, psychiatrists played a pivotal role in accomplishing the redefinition.
By the mid-1950s, in many hospitals, physicians assembled themselves collectively into abortion boards or committees. As a group, obstetricians, cardiologists, psychiatrists, and others considered abortion recommendations and requests and issued definitive decisions on each case. The chief of a department of obstetrics and gynecology in a large northeastern hospital described the way decisionmaking processes changed in many hospitals in the early 1950s.
At Mount Sinai Hospital [in New York], before [Alan Guttmacher’s innovations], a request for therapeutic abortion merely had to be signed by two senior staff members. Guttmacher established the abortion committee of five members: the chief in medicine, representatives of pediatrics and of surgery, the chief of psychiatry, and the chief of obstetrics and gynecology who acts as chairman. Requests to the committee must be supported by two consultants recommending the procedure and outlining the indications for it. One of the consultants must appear before the committee to answer additional questions. The committee must be unanimous in its approval of any request.
These committees protected physicians, individually and as a profession, in a number of ways. Of paramount importance to many was the legal protection the boards provided. Four medical doctors, characterizing the therapeutic abortionist as a “fetal executioner,” stressed that group review of all cases was crucial because the “legal burden” otherwise rested on the individual obstetrician. The Journal of the Indiana Medical Association recommended group work early in the crisis: “To make as certain as human precaution can make it, that a physician might not be subjected to difficulties later on, he should have consultation with other physicians. . . .” Another group of medical doctors studied the legal situation in Michigan in 1950 and determined that hospitals were compelled to establish abortion committees in order “to protect the physician” because “while abortions could be performed legally [in that state, if the mother’s life was in danger], in the event of suit, the physician had no legal protection,” in the absence of a committee. Rudolph W. Holmes insisted that because the law drew such a “tenuous” line of demarcation between legal and illegal abortions, “it behooves medical staffs of all reputable hospitals to institute [abortion boards]. It would be a great protection to the operator as well as a deterrent to dangerous aspersions by outsiders.”
For many concerned physicians, insiders could be as dangerous as outsiders. These medical doctors felt that committees functioned best to mute, neutralize, or “curb liberal obstetricians” favoring too many abortions or abortions on questionable grounds. The California survey conducted in the mid-1950s and reported in the Stanford Law Review revealed that most physicians in the twenty-six reporting hospitals felt that the committee’s central function was “to police activities of a doctor whose procedures might otherwise bring himself and his colleagues into disrepute.” A number of medical doctors simply described the structure as “an effective method of control.”
These interests in reputation and control were undoubtedly central concerns of many physicians in part because so many of them spoke and behaved one way publicly and another way privately. For example, a number of professional, illegal abortionists who conducted thriving businesses in this era have reported that hundreds of medical doctors–surely among them, those who publicly claimed medical, hospital control over abortion decisions–routinely referred clients for illegal abortions. By insisting on the righteousness of the mechanisms of hospital abortion committees, physicians could disassociate themselves from professional and public concerns about widespread illegal abortions, thus diminishing personal vulnerability and, perhaps, individual crises of conscience.
Moreover, as Carole Joffe has recently demonstrated so vividly, a number of respectable medical doctors–she calls them “physicians of conscience”–performed thousands of abortions in secret in these years, because of their deeply held conviction that women should be able to choose whether and when to have babies. These physicians of conscience were serving a function for many of their law-abiding colleagues who regularly referred unhappily pregnant girls and women to them. They were also symbols of the broken ranks of the profession and represented a threat to that profession’s probity and its safety. Because, apparently, so many hundreds of obstetricians, gynecologists, psychiatrists, and others were at least second-party participants in illegal abortions, the hospital abortion committee became important as it promoted the fictions of medical solidarity and the profession’s legal compliance.
Many contemporary commentators referred to the actual legal vulnerability of physicians who performed abortions as a “phantom,” and many pointed out that “no reputable physician has ever been convicted for performing an abortion in a reputable hospital.” This was the case both before and after abortion committees began to operate. It seems probable, then, that the most valuable service the boards actually performed was to bolster the image of physicians as members of a highly functioning professional body guided by scientific expertise and collective wisdom. The committee could transform public dissension within the medical community into public harmony, and at the same time, reduce the incidence of abortion. Careful study of the early functioning of one abortion committee showed that requests had fallen dramatically and “that the indications proposed during [the second year] conformed more to medical practice.” Two medical doctors, reflecting on their three-year experience on an abortion board in Newark, New Jersey, lauded the structure because of its “impartial, anonymous, efficient performance.” Incidentally, these physicians provided an example of how such scientific, expert qualities shaped the board’s decisionmaking. Two women who had contracted rubella, one at six and one at nine weeks gestation, applied for permission to abort but were rejected by the committee became in both cases, the illness was “not objectively observed by a physician.”
Moreover, physicians could more confidently assert their right and duty to retain medical control over the abortion decision once they established the committee as a respectable forum dedicated to processing individual women in an orderly fashion. In short order, the committee became a vehicle for bringing professional wisdom to bear on the issue, in part as a way to forestall the situation “where the decision for abortion may be made by legal, social or welfare groups outside of the profession.”
In an era when the law was increasingly positioned between the medical practitioner and the patient, many physicians recognized a need not only to reassert a proprietary role in the abortion decision but also a need to assert, through the abortion board, medical doctors’ intentions to carry out their medical responsibility judiciously, even judicially. Facing a discrepancy between hospital by-laws and state laws governing permissible abortions, physicians constituted the abortion committee as a quasi-legal forum and associated themselves with the wisdom and objectivity of the law. In this way, they also courted and apparently won the trust and respect of the legal profession, as well as a measure of protection against liability. Obstetricians, reporting on the success of the committee in one hospital, pointed to two outstanding achievements. First, abortion requests had almost halved since the board was established. And then, “another way of assaying the value of our committee is the informal opinion of our legal friends as well as a Judge of Probate Court that . . . all physicians [should] have the benefit of such committee approval. . . .”
As physicians assumed a judicial role regarding individual requests for abortion–whether the requests originated with the obstetrician, another medical specialist, or the pregnant woman herself–inevitably, committee physicians, donning their robes in earnest, perceived the individual woman as “on trial.” Unfortunately, however, in many cases, the cardinal principle of the U.S. legal system seems to have been inoperative. Physicians warned each other not to assume the woman’s innocence. A New York medical doctor put it this way: “The physician must have a high index of suspicion for the patient who tries to pull a fast one.” The source of danger was the “individual [woman] seeking to satisfy selfish needs”; the consequences of ignoring the danger were “somewhat analogous to medical opinion in any industrial compensatory action in which motivation may play a large role, and medical practice can be degraded.” One physician spoke for many of his colleagues when he warned of the “clever, scheming women, simply trying to hoodwink the psychiatrist and obstetrician,” when they asked permission to abort. Another identified “woman’s main role here on earth as conceiving, delivering and raising children.” Thus, he concluded, any woman who claims not to want a certain pregnancy, must not be believed. In this environment, it is not surprising that, as one physician put it, “we have had a great many less requests for abortion [in his California hospital] since the patient and the doctor know that the patient must . . . have her case become an open trial so to speak to be decided on its merits.”
In order to function successfully, abortion committees accepted additional assumptions about the relationship between abortion, medicine, and the role of the medical doctor. First, many physicians stressed the traditional, exclusive relationship between medical science and the individual patient, a relationship that could best be honored and protected by the committee of medical scientists. In this case, the individual was a simply biological or organic entity; social, economic, or other environmental factors were irrelevant to an individual pregnant woman’s situation and to an abortion determination. Two physicians who felt that some of their colleagues were being inappropriately swayed by what one called the “intense [non-medical] motivations” of importuning women, cautioned:
It would seem that a few abortions were brought about through the combined influence of economic pressure, social factors, and convenience. To deny that these forces had not influenced us would be incorrect; to accept them would be unwise; and the best course would be to view future indications in the light of strict medical principles directed toward preserving the life and health of the mother.
Six years later, another medical doctor referred to the “real need” to disregard any but the strictly medical indications present in the individual pregnant woman. To stray from this focus was to stray from science and from the physician’s role as a medical healer. It was also an invitation for critics to impute social or political or unethical agendas to medical doctors. For example, those who exceeded their medical expertise could be accused this way: “To specify certain social indications for legal abortion is equal to legal license for the abortionist”; or this way: medical doctors who granted permission liberally, on the other-than-medical grounds, perhaps did so because they “enjoy this procedure” and because of a “complete lack of professional and moral principles [which leads them to] do anything out of a desire to win a friend or to make a dollar.” Holding a tight focus on the individual sustained the pregnant woman as a scientific specimen which could be viewed against a neutral background. The physicians’ task could be sustained as scientific. Medical doctors need not, indeed, they must not, assume the role, particularly, of social critics. Although the objectivity, the neutrality, anonymity, and dignity of the law had something to offer medical doctors considering the abortion issue, in the 1950s the sociologist’s arena was a minefield.
There was, however, one way that social science could support and validate therapeutic abortion practices in hospitals in the postwar years. By this time, statistical information was widely recognized by sociologists, psychologists, political scientists, educators, and other academics and public policy experts, as a highly valuable legitimating tool. Numbers became a valid basis for explaining, analyzing, predicting, and even justifying behavior. Inferences and conclusion, policies and politics based on statistics became “scientifically valid.” As part of this trend, abortion committees agreed to practice scientific medicine by statistics. Drawing on this development, one participant asserted that “the need for therapeutic abortion should be no higher than one per one thousand maternities.” A critic of this general orientation observed that many hospitals were “now practicing abortion by statistics [so] the patient is no longer a medical case but a number balanced against a quota. If she arrives after the monthly quota has been filled, she may well be rejected despite the urgency of her medical needs.” One report of hospital practices cited a “gynecologist [who] said his place had gotten a reputation for being easy, so tightened up and now approved one in ten.” Similarly, Alan Guttmacher in New York said that his hospital, Mt. Sinai, was formerly saddled by the reputation of being an easy place to get an abortion. As a consequence, he set up an abortion board. “The result is that applicants for interruption of pregnancy have decreased tremendously because of the vigilance of the board and the fact that the case has to go through such a procedure.”
A number of studies argued for the efficacy of committees on the simple grounds that abortions decreased after the boards were established. In this additional respect, then, committee-based, statistically shaped abortion decisionmaking bolstered the reputation of the medical profession as a collectivity of scientists. At the same time, practitioners protected themselves from outside negativity. Low statistics demonstrated good scientific, nonideological practice. One commentator reported that the fear of being labeled with the reputation of “abortion mill” was so pervasive among hospital staffs in the postwar era that “many hospitals now consider a minimum abortion rate a status symbol. ‘The fewer abortions, the better we look,’ a Philadelphia doctor put it.”
Finally, as suggested earlier, although the psychiatric perspective had been initially problematic for many medical doctors involved in abortion determinations, by the late 1950s, the situation had changed. By this time, the abortion committees had provided psychiatrists with a rich proving ground for their specialty. According to a number of essayists, psychiatrists did rise to the aid of their colleagues by providing the expert basis for medical decisionmaking and medical control that would have otherwise been lacking. As the biology of both disease pathology and pregnancy became less mystified and less remote because of medical-technological advances, psychiatrists stepped in, forestalling the possible empowerment of the pregnant patient. Psychiatrists constructed and drew on the unconscious as an entity which was only accessible to, and could only be decoded by, the expert. One physician observed, “If we have learned anything in psychiatry, we have learned to respect the unconscious far more than the conscious and we have learned not to take [abortion requests] at face value.” Another demonstrated how this observation worked in practice. “An example is a woman who comes in seemingly with an unambivalent wish to be aborted which, upon interview, turns out to be an unconscious attempt on her part to punish her husband. Such a discovery, as the basis of diagnosis, could only be available to the physician.
Pregnancy Redefined
This physician and many of his colleagues were, in part, responding to the new pressure from many women in their offices initiating requests for legal, therapeutic abortions. They were also responding from a new definition of pregnancy itself which emerged following the decline of medical indications for the interruption of pregnancy and alongside the validation of the psychiatric perspective.
Pregnancy became, at this time, a state inhering to the woman-as-custodian, but the pregnant woman and fetus no longer presented an integrated system. In the postwar period, pregnancy was no longer viewed as an “added burden” or an “increased load,” or a potentially destructive agent. It remained, under the proper circumstances only, a fundamental expression of womanhood, inexorable and transcendent, but something dramatic had happened to the essence of pregnancy. After medical doctors determined that there were no longer any medical contraindications to pregnancy, pregnancy ceased to be a physical issue. Physicians now argued that “for most conditions, the natural history of the disease is not influenced deleteriously by an intercurrent pregnancy. Convertly, neither is the course of pregnancy seriously affected by a complicating medical condition.”
Neither did physicians consider pregnancy a psychological issue. One argued: “Statistical analysis shows that childbearing has only a small influence on the mental disorders of women and that the majority of individuals predisposed to mental disorder go through childbirth unscathed.” Regarding psychological treatment, medical doctors were confident that “the presence of pregnancy does not interfere with the treatment of psychiatric disease or make it less effective; in fact, we do not hesitate to administer electric shock therapy with curare while the patient is pregnant.” Summing up the position of many, two obstetricians wrote, “As far as a complicating disease is concerned, the expectant mother presents a problem not greatly different from that of a non-pregnant sister with the same disease, and . . . furthermore, so far as her pregnancy is concerned, she is not greatly different from other pregnant women.”
In essence, pregnancy was most centrally a moral issue, but the moral ground had shifted. As the fetus was constructed as a little person, medical doctors constructed the pregnant woman’s body as a safe reproductive container. The woman, along with her physician, had the moral duty, to sustain the container as fit. One obstetrician explained the suitability of women for this role. “Woman is a uterus surrounded by a supporting organism and a directing personality.” Completely effaced, the woman-as-uterus simply housed the child. The most perfect iconic expression of this refocusing burst upon the consciousness of the general public in this country in the pages of Life magazine in April 1965. There were displayed the amazing photographs of Linnert Nilsson, a Swedish photographer, who had spent seven years working with surgeons in five Stockholm hospitals, to capture images of the fetus in utero at many stages of its development. The photographs demonstrated two startling conceptual innovations. First, in Nilsson’s pictures, each frame is filled entirely by a fetus in the uterine environment, but no woman, no mother, no hint that the fetus is in relation to any other living entity. The fetus is ultraprivileged and apparently ultraindependent. The images suggest that if there is a woman involved in this “life before birth,” she occupies another space, if not another universe, entirely. Second, the pictures aim to capture, most importantly, the humanness of the “baby.” Nilsson selected to focus on the eyes, the faces, the hands and feet, to stimulate the viewers’ sense of sympathy and identity with the fetus. The photographer intends to portray the thirty-seven-day-old, one-half-inch fetus as baby. The embryo with a human face demands a morally nourishing environment. Providing that had become the pregnant woman’s job and the meaning of pregnancy.
It is important to note here a shocking irony regarding this pictorial event. Tiny, inconspicuous text accompanying the photographs indicates that almost all of the photographs were images of embryos that had been “surgically removed for a variety of reasons.” The text doesn’t indicate from what or whom they had been “removed.” So without any clues about this fact attached to any individual picture, indeed, it was the case that these fetuses were independent, if dead.
Drawing on the innovative notions of pregnancy and pregnant women, psychiatrists were prepared to explain the behavior of the growing number of women asking medical doctors for abortions in the postwar years. Their explanations created a broad category of women who were, by definition, in the absence of traditional medical problems, morally and psychologically unsuited for childbearing and certainly for motherhood because they were unwilling to serve as pregnancy vessels. Where there was an unhappily pregnant woman, there was a defective vessel. Many medical doctors agreed that an abortion could be performed on such a woman, but the procedure would not help as the problem was not the pregnancy. The problem was called a “psychiatric disorder” involving the woman’s denial of her destiny and “amendable to treatment” as such. But the tone of the diagnosis, like the tone so often used to judge women on one grounds or another in these years, dripped with moral rectitude and condemnation. One psychiatrist identified the request for abortion “as proof [of the petitioner’s] inability and failure to live through the destiny of being a woman.” Another, already cited, named motherhood as woman’s “main role on earth.” Arguing that abortion inevitably damaged women, he chimed that “despite protests to the contrary [and] . . . despite other sublimated types of activities,” pregnancy and motherhood were “still their primary role.” Going a step further, a psychiatrically oriented New York obstetrician insisted that most women experiencing unwanted pregnancies–whether or not they sought abortions–were “immature, psychoneurotic, or under emotional stress,” not the victims of contraceptive failures.
Again, consistent with the generally misogynistic and moralistic judgments experts offered at this time, there was a broad consensus among many essayists in the medical journals and elsewhere that unwillingness to provide a safe environment for the fetus revealed a deeply rooted history of mental illness. One medical doctor found that “the patient, who all her life has disliked being female, found herself in conflict with men, and feared motherhood may be particularly abortion-prone. . . .” He cited the work of another specialist who identified two types of women likely to refuse pregnancy for psychological reasons: ( 1) “The basically immature woman who cannot accept the outstanding responsibility of mature femininity, namely becoming a mother”; and ( 2) “The independent, frustrated woman who has been conditioned to and yearns for the rewards of the male world and feels that maternity, the greatest reward of the female world, is much less satisfying–in fact, highly unsatisfying.”
A physician who responded to such a woman’s expressed desire to violate her destiny was, according to many, in serious error. One highly experienced author-psychiatrist placed women who chose abortion on a sullied moral plane when he asserted that he had “never seen a patient who has not had guilt feelings about a previous . . . abortion.” Others felt that because the pregnancy itself was not the source of difficulty, an abortion did not solve a woman’s problems but could create serious problems for her. For example,
[Abortion] coupled with ideas of guilt, self-deprecation, some recurrent preoccupation centering around the abortion and the general theme of “I let them kill my baby” might well disturb a poorly integrated personality even to psychotic proportions. Feelings of love, admiration and respect for the male partner . . . may well be distorted in the aborted woman to ideas of disgust, hate, and disrespect; “He gave me a baby then took it away.” The unconscious motivation and even the flow of emotions during the readjustments to a normal sexual nonpregnancy cycle may result in deeply engrained feelings of hostility toward the husband. Abortions we may say can produce psychotic cicatrix.
Indeed, husbands were often defined as the worst victims of abortion. A psychiatrist described what he had observed were its most common psychiatric sequelae:
Psychiatrists see patients who accuse themselves . . . of being murderesses and then who go into very pronounced depressive reactions. We see patients who deliberately afterwards punish themselves or their husbands by forcing vasectomy upon them, or in other ways–sometimes unconsciously, but very frequently on conscious levels deliberately castrating their husbands–usually emotionally, but occasionally, even in actuality.
Another physician argued that abortions were beside the point because “women who are physically vulnerable” will eventually and inevitably deteriorate. The pregnancy was beside the point, as well: “It seems to matter little with regard to future mental health whether the pregnancy is terminated or not. Those who are going to react adversely will do so irrespective of the procedure.” Conversely, a psychiatrist in Birmingham, England, cited the work of his colleagues as a warning to abortion-prone doctors: “Pregnancy appears to have a protective effect against the manifestations of mental disorder . . . many psychotics and neurotics show quiescence of their symptoms during pregnancy itself.” In this case, hardly an “added burden,” pregnancy becomes a variant of electric shock therapy.
In sum, the rise of hospital abortion committees and the redefinition of pregnancy in the postwar years reflected and intensified a broad cultural interest in reaffirming and reasserting male authority over women. The method of achieving male control described here was a typically insidious example of this effort, because the language created by the new insights about the nature of pregnancy required that pregnant women be disempowered. That is, the new “moral” essence of pregnancy was built upon a presupposition of judgment and control. When physicians defined pregnancy as a moral issue and counseled women to cooperate in sustaining themselves as moral and fit containers for fetuses, they demanded that pregnant girls and women cooperate in accepting the terms of their own oppression. Resistance had become a moral issue and, in effect, an immoral act.
Women Threaten Suicide
Well-known to unhappily pregnant women in the postwar era, however, was one method of resistance that sometimes cut through the language of morality: the threat of suicide. This condition alone raised the specter for medical doctors of a reintegrated mind, body, and pregnancy. A pregnant woman’s threat of suicide suggested that the woman might destroy the reproductive container which gave definition to her very existence. Women recognized early that they could get their medical doctors’ attention by making such a threat, but many physicians found it easier to believe that a woman was using her pregnancy rather than throwing away her destiny. Thus, physicians proceeded very cautiously in this area. One wrote that “a mere threat of suicide or even an abortive attempt at suicide is not in itself regarded as a medical indication for therapeutic abortion; it may be nothing more than an effort to blackmail the surgeon into performing the operation.” An obstetrician at Columbia-Presbyterian Medical Center in New York explained his position:
I have been very much disturbed by the use of the indication of reactive depression with suicidal tendency. In cardiac disease you at least have an occasional death to validate the indication. I have not in my experience ever run across a suicide in pregnancy in a patient who was suffering from anxiety depression. . . . I think that one of the honest reasons for the reduction in the number of therapeutic abortions in the last ten years is that the obstetricians are concerned with the subterfuges that are being employed, otherwise they might be willing to be much more lenient.
The abortion board at one hospital had been in operation for three years by 1960 and had adjudicated a number of requests from allegedly suicidal women. Lewis E. Savel and Irving K. Perlmutter gave examples demonstrating how the committee members were able to identify which of the petitioners should be denied permission. “One [woman] was a 40-year-old gravida v, para iv, who threatened suicide. The opinion was that such feelings were often verbalized by many women having an undesired pregnancy.” This petitioner was denied an abortion. Two additional petitioners were similarly inclined but in both cases, “the psychiatric situation was judged too superficial to warrant intervention.” Another exemplary case described “a girl of twenty [who] was referred to a gynecologist at a large teaching hospital. Staff psychiatrists saw her to pass final approval [for the abortion]. When they rejected her . . . it was their opinion that while ‘allowing the pregnancy to continue will undoubtedly cause further deterioration in her schizophrenic process, we do not think she will kill herself.'”
The survey reported in the Stanford Law Review provides an excellent example of a suicidal pregnant woman who physicians were willing to believe deserved an abortion. An unprecedented 80 percent of reporting hospitals agreed to sanction abortion in this hypothetical case.
Mrs. C. is 32 years old and is the mother of children, aged 7, 4, and 3. Following the birth of her last child, she had what was diagnosed as a postpartum depression in which she became completely withdrawn. She was hospitalized in a state hospital for 6 months during which time she had electroshock therapy with some improvement. She has remained under psychiatric care since then but she still becomes depressed very easily and talks freely about committing suicide, saying that her family will be better off without the burden of her care.
Four weeks ago it was diagnosed that she was approximately 4 weeks’ pregnant. The news of this precipitated a severe emotional crisis. This has been manifested by vomiting, spells of uncontrollable crying lasting for hours at a time, at which time the patient locked herself in her room. She threatened suicide several times in the last four weeks, saying that she could never be a “good mother” and that she was a “useless member of society.”
Last night Mrs. C. was found unconscious on the floor of her living room. There was an empty bottle, which should have contained approximately eighteen sleeping pills, in her bedroom. She was taken to the hospital and has apparently responded to vigorous therapy for her barbiturate overdose.
Mrs. C.’s case evoked near-consensus because this woman demonstrated her commitment to destroy the reproductive container she had become. Only in the case of such a demonstration could the moral dimension be eclipsed and the condition of pregnancy assume its previous status as an “added burden” or a destructive agent.
Doctors Threaten Sterilization
The other way that physicians frequently revealed their commitment to the new construction of women’s bodies as reproductive containers was in their association of therapeutic abortion with simultaneous sterilization. As one chronicler of this era put it:
Patients actually had little or no contact with the operating physicians and often learned, only well after the fact, that the abortion had included sterilization. Because abortion patients were viewed as “psychotic,” “hysterical,” “depressed,” “neurotic,” or “guilt-laden,” the symptoms associated with what psychiatrists . . . term the “post-abortion hangover,” the patient was considered to be in an unfit mental state to evaluate her own treatment. Early supporters of the psychiatric route believed that the abortive woman not only lost her baby, but rejected her own womanhood as well. The belief in woman-as-childbearer, a paramount function, undergirded the entire therapeutic structure.
The prevalence of sterilization was widely featured in the obstetrical and psychiatric literature of the day, specifically in cases involving what one prominent expert called the “tainted individual.” One group of obstetricians found that “some women desiring an abortion were required to have a simultaneous sterilization operation as a condition of approval of the abortion in from one-third to two-thirds of [those] teaching hospitals [studied] in different regions of the country. In all, 53.6 percent of teaching hospitals made this a requirement for some of their patients.” Another physician reported his finding of a 40 percent concomitant sterilization rate in all U.S. hospitals in the 1940s and 1950s. A Chicago study of 209 aborted patients showed that medical doctors at the Lying-In Hospital in that city determined, “In the majority of cases when therapeutic abortion is indicated, the patient’s medical condition warrants the prevention of future gestations”; 69.4 percent of these women were sterilized.
Some physicians justified simultaneous sterilization on the grounds that any woman ill enough to warrant abortion should never again be pregnant. Others shared this position but shifted the emphasis on to the medical doctor’s dilemma: “A serious effort is made to control [by sterilization] the need for dealing with the same problem in the same patient twice.” A California psychiatrist described what he felt was a strong trend among medical doctors, “penalizing” by sterilization the patient who “needs” a therapeutic abortion. He explained the practice this way: “Often, the surgeon’s stipulation for sterilization may reflect his reluctance to perform the abortion, his misunderstanding of its necessity, and his resentment of the psychiatric indications.” Another commentator felt that some physicians in this era resented sexual women more than they resented psychiatry: “The abortion committee [at one hospital] evaluated all patients in terms of recommendations for sterilization. Medical grounds for this ‘final solution’ to ‘promiscuous’ abortions were forcefully debated by individual members and typically included the physician’s evaluation of the woman’s condition and moral character.” The widespread use of sterilization, whatever the expressed justification, seems to suggest that many physicians in the postwar era were willing to use the sterilization option to cap the defective reproductive container. In one small midwestern hospital, four requests for therapeutic abortion were presented to the committee one year. None was approved. Among them was this case: “Approval of both therapeutic abortion and sterilization was requested for a 36-year-old gravida iv, para ii for arrested pulmonary tuberculosis, thyrotoxicosis, and emotional instability. Despite the consultants’ recommendations the committee did not approve the abortion, but did approve postpartum sterilization.”
One physician, unhappy about the coupling of sterilization and therapeutic abortion in U.S. hospitals, observed that this practice actually drove women to illegal abortionists to escape the likelihood that a legal abortion would entail the permanent loss of their fertility. He added, “I would like to point that out, because the package [therapeutic abortion-sterilization] is so frequent I therefore consider them fortunate to have been illegally rather than therapeutically aborted, and thus spared sterilization.” This aspect of the discussion foreshadowed, of course, the legal institutionalization, in our time, of the link between abortion and sterilization, via the Hyde Amendment.
The Limits of Abortion Committees
The literature reviewed in this essay makes it clear that some influential medical doctors in the postwar era derived professional strength and ideological coherence from abortion committees and from a new, disembodied definition of pregnancy. But by the middle of the 1960s, it was also clear that the same factors which had pushed physicians into a defensive posture in the early postwar years continued to exert considerable pressures on the profession. These and additional factors combined to facilitate the eclipse of medical authority over the abortion decision much sooner than many practitioners had predicted.
Over time, the committees themselves could not sustain the image of professional unity and scientific purpose, even if an individual hospital could issue abortion decisions with one voice. Harold Rosen, a prominent medical doctor interested in abortion reform, noted widespread inconsistencies between hospital abortion committees in the mid-1960s which hurt the credibility of the profession.
Not infrequently, for instance, the abortion board of one hospital, but not another, may refuse to accept a recommendation for interruption; on nine separate occasions during the past seven years, patients who have been seen in consultation in one hospital have afterwards been therapeutically aborted at adjacent hospitals with, at times, almost the same visiting staff.
At the heart of this apparent capriciousness was a continuing inability among physicians to agree on indications, even medical indications.
If physicians do not wish to force a specific woman to carry a specific pregnancy to term, and if that woman is actually suffering from some severe physical disease then, but only then, the pathological process, provided it falls within certain categories, is in certain hospitals and by certain physicians and hospital boards considered sufficient indication for interruption. In others, it is not. . . .
In addition, Rosen noted that the medical profession continued to be rent by the abortion issue as the direct result of both medical progress in managing pregnancy and “undeclared nonmedical factors,” specifically the pressure of the legal threat against physicians and restrictive legislative statutes. These factors persisted in conditioning the abortion decisions of medical doctors despite attempts to neutralize them and despite the fact that they were rarely, if ever, in fact prosecuted for performing therapeutic abortions in hospitals.
Other factors which exerted increasing pressure in the abortion arena include first, of course, women’s growing insistence on breaking the link between law and medicine, so that women themselves could take the power to decide who was a mother and to decide when a woman was a mother. After the rubella epidemic and the thalidomide episode of the early 1960s, women also began to insist on a legal, publicly sanctioned right to decide who was a child. The sensationally and intrusively reported plight of Sherri Finkbine in 1962 raised, above all, the specter of the pregnant woman’s right to reject a fetus deeply damaged by thalidomide.
Additional pressures which struck at medical authority came from the flowering of the quality of life (or “life-style”) ethic among the middle-class in the United States which undermined the acceptability of the simple life/death dichotomy that the law mandated must govern abortion decisions. Also, in the 1960s as social criticism seeped back into mainstream public discourse, some physicians began to accept and use a definition of the purpose of medicine–in this case, of indications for abortion, which placed unhappily pregnant women in desperate social and economic contexts. Physicians were also involved in and influenced by the reemergence in this era of a holistic approach toward diagnostics and treatment which reflected and promoted the other two emergent trends of the 1960s. One contemporary commentator applied these trends to the abortion issue in this way:
Distinctions between physical and mental health are meaningless in terms of modern medical thinking. Health cannot be divorced from socio-economic factors which influence people’s lives since health is a product of these conditions. In applying criteria for abortion based on maternal health, the question should be the extent to which the pregnancy threatens the general well-being of the patient.
Of equal or greater importance to all these pressures undermining medical authority in the abortion arena by the mid-1960s was widespread concern and fear among whites in the United States about the “population explosion,” rising welfare costs, the civil rights movement, and the “sexual revolution.” Critics of these social, political, and cultural phenomena tended to target women’s bodies and their reproductive capacity as a source of danger to the fabric of U.S. society. Demedicalizing and decriminalizing the abortion decision became one way to diminish the damage women’s bodies could do.
Conclusion
This essay leaves unexplored many issues that would shed additional light on the concerns and strategies of medical doctors sitting on hospital abortion committees in the postwar era. These include physicians’ attitudes toward abortion and women of various races, ethnicities, and classes. Much research is needed in this area. The essay does not explore medical doctors’ attitudes toward and relationships with illegal abortionists, a subject well worth pursuing. Also left unexplored are the sources and complex nature of physicians’ changing attitudes toward abortion in the 1960s and 1970s. Pregnant women themselves have not been given voice in this essay.
But the subjects of this study, a highly visible segment of the medical community, have been given voice here in order to allow us to consider what was at issue for many physicians in the immediate pre-Roe v. Wade decades. What is most striking in the literature reviewed for this essay is that, with the exception of the few articles prepared by Catholic medical doctors, the physicians who wrote on the abortion issue were not primarily concerned with the issue of when life begins. They were, however, very concerned with what they took to be their role in the postwar cultural mandate to protect and preserve the links between sexuality, femininity, marriage, and maternity. They were also deeply concerned about their professional dignity and about devising strategies to protect and preserve the power, the prerogatives, and the legal standing of the medical profession.
An important strategy of many physicians in this era was to draw on the vulnerability of pregnant women to construct a definition of pregnancy that effaced the personhood of the individual pregnant woman. This definition created a safe place for the fetus and also for the physician forced by law to adjudicate the extremely personal decisions of women, many of whom were resisting effacement. The subordination of the pregnant woman to the fetus revitalized medical participation in the abortion decision because the medical doctor was now required to make sure that the woman stayed moral, that is, served her fetus correctly. These postwar ideas demonstrate the relationship between scientific advances and ideological positions regarding women, pregnant women, pregnancy, and fetuses. Physicians have often presented these positions as scientific, providing “evidence” for antichoice proponents. It seems clear today that if abortion decisions were again assigned by law to medical doctors, unhappily pregnant women seeking abortions would again confront a defensive profession, masking as scientists for this purpose, but constrained to practice ideological medicine. Perhaps the most difficult task for prochoice advocates today, and the most crucial, is to insist with even more vitality that they occupy the moral ground. Pregnancy is not, by definition, the moral duty of girls and women; rather, granting this population reproductive freedom is the moral duty of society.