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The Remarkable Safety of Illegal Abortion
I spent significant portions of the last few weeks pouring through the National Abortion Federation's most recent medical textbook on abortion. Published in 2009, it's titled: Management of Unintended and Abnormal Pregnancy. The subtitle is a bit more straightforward: Comprehensive Abortion Care. For the National Abortion Federation (NAF), abortion is the de facto management solution for unintended or abnormal pregnancy, and this book teaches physicians how to perform them. By the time I finished reading the almost 400 pages of text, I found myself staring down at 23 pages of notes. Needless to say, it was an informative read – both for what it said and didn't say.
Following the lead of Warren Hern's much earlier volume, Management of Unintended and Abnormal Pregnancy does not address the morality of abortion. In other words, it never troubles itself with an attempt to explain why it is ethically sound for a physician to intentionally end the life of a living human being. And though the book deals at some length with "abnormal" pregnancies, it readily affirms the fact that at all stages of pregnancy, "most women seeking abortion are young and healthy." (159) Only 12% of women in the United States list a physical problem with their health among their reasons for having an abortion. (78) The closest this book comes to a moral argument is found in the second foreword, when Malcolm Potts writes:
Bernard Haring, who has been called "the foremost Catholic moral theologian of the 20th century," wrote "The moment of ensoulment . . . does not belong to the data of revelation." If, "the moment of ensoulment" is indeed a matter of faith, then religious freedom must encompass different interpretations of abortion. In short, in any society that separates church and state, the status of the embryo-fetus is a matter of personal, usually religious assertion; and like other religious assertions, it must remain a matter for tolerance. Logically, any pluralistic society built on religious tolerance must permit safe abortion. xiv
Later in the book, the authors declare that though "some abortion care providers may find it difficult to accept sex selection as a valid reason for an abortion… [the patient] may believe that aborting a female fetus is a rational act for the future good of the family." (60) Physicians are advised to yield to the moral compass of their patients, so as to "provide care in a nonjudgmental way." (325) None of these are moral arguments. Rather, these are arguments to be amoral physicians, and none of them bear up under scrutiny. The argument put forward by Malcolm Potts is ridiculous on its face. Does anyone suggest tolerance for religions that practice child sacrifice or even animal sacrifice? How about for religions that practice cannibalism, slavery or bigamy? Do these practices get a free pass as well? Biology tells us unequivocally that abortion kills a living, genetically-distinct human being. This is not a religious assertion. It is a matter of plain, empirical evidence. Therefore, it is folly to argue that abortion must be protected for the sake of religious freedom. We do not demand health care providers to be nonjudgmental if they encounter child abuse or rape. On the contrary, we expect them to intervene on behalf of the victim. Why should it be any different in the context of abortion?
In lieu of a moral defense of abortion, the NAF textbook relentlessly asserts that abortion is simply unavoidable. Consider the following remarks:
- …women who do not wish to be pregnant for whatever reason will attempt to terminate the pregnancy, regardless of the risks involved. (x)
- When faced with unwanted or unintended pregnancies, women resort to induced abortion irrespective of legal restrictions. (10)
- Legal restrictions on abortions have little effect on women's propensity to terminate an unintended pregnancy. (12)
- Legal restrictions do not eliminate abortion; instead, they make abortions clandestine and unsafe. (20)
Why do they go to such great lengths to make such a statistically dubious assertion? Because it's a lot easier than trying to defend the practice of abortion in its own right. By asserting, over and over and over, that women will have abortions whether they're legal or not, the NAF is trying to sidestep the ethics of abortion. In an attempt to make the morality of abortion superfluous, they've landed on the following hypothesis:
a) Women will abort whether it's legal or not.
b) Illegal abortions are unsafe.
c) Abortion must be legal.
Framing the issue this way essentially concedes the immorality of abortion, but argues that it must remain legal – lest women be killed en masse from illegal abortions. There are two glaring problems with this hypothesis, and both are demonstrable from the pages of the NAF textbook itself. We'll start with page 32, where it says: "Studies have found that public funding of abortion makes services accessible to women who would otherwise carry unintended pregnancies to term." In advocating that more public money be spent to pay for abortions, the NAF admits that a woman's decision to abort is influenceable. After spending the first two chapters hammering away at the notion that not even the law can prevent a woman from having an abortion, they admit that a mere lack of funds is enough to keep many women from aborting. In chapter four, the authors lament the preventative impact parental notification laws are having in some states even as they note that "in states where no legal challenge is possible, abortion providers and advocates have devised systems to help minors obtain bypasses as efficiently as possible." (41) Here again, if legal restrictions have no bearing on a woman's willingness to abort, why does the NAF have to devise such elaborate networks of attorneys and judges to circumvent parental notification laws? Finally, the NAF textbook criticizes Mississippi's recent "two-trip" legislation for reducing the state abortion rate by 15% in 12 months. By simply requiring patients to visit the abortion clinic twice instead of once, Mississippi reduced the overall number of abortions. If it were really true that nothing can dissuade pregnant women from aborting, these results would have been impossible to achieve.
The second problem with the NAF hypothesis relates to premise b, and this is where I want to place most of our focus. Even if we concede the first assertion–that the law has no bearing on a woman's willingness to abort, the second assertion is just as untenable. Here's why. Though the legalization of abortion is often credited with reducing abortion's morbidity and morality rate, it was technological changes that played a far more significant role. To demonstrate, consider the bullet points below, all taken directly from the pages of the NAF text:
- Around the period of legalization in the USA, technological advances in the field of abortion care facilitated new models of abortion delivery. Specifically, development of the vacuum aspirator, cervical anesthesia methods, and the Karman cannula all improved the safety of abortion and permitted its provision in nonhospital settings. (3)
- The high risk of death from unsafe abortion in Africa reflects the procedures used and the poor availability, accessibility, and quality of services for management of complications. (19)
- The remarkable safety and technical simplicity of early modern induced abortion place it well within the scope of practice of diverse types of clinicians… appropriately trained clinicians can provide first-trimester aspiration or medical abortion with an impressive safety record. (135)
- First-trimester aspiration abortions performed in an office or clinic are as safe as those performed in hospitals. (137)
- First-trimester aspiration abortion is one of the safest procedures provided for women of reproductive age. Its use in lieu of dilation and sharp curettage has reduced abortion-related morbidity worldwide. (152)
- The US adoption of laminaria tents in the 1970s to dilate the cervix before uterine evacuation represented a landmark in abortion care, permitting safe D&E later in pregnancy. (158)
- … the favorable safety profile of D&E makes the procedure amenable to a variety of clinical settings. (159)
- Most women seeking early medical or aspiration abortion can be safely treated using only clinical assessment, saving ultrasound and laboratory tests for the occasional patient who cannot be evaluated otherwise. (320)
- Medical abortion… can be administered and managed by nurses, midwives, and other trained personnel. Trained midlevel providers can safely and effectively perform vacuum aspiration, the standard treatment for failed medical abortions, thus enabling delivery of medical abortion in decentralized areas that few or no doctors. (322)
The NAF's interest in demonstrating the technical simplicity and overwhelming safety of first-timester abortion owes to its desire to see abortion further deregulated. But such claims counteract the overarching assertion that for abortion to be safe, it must be legal. And lest you feel I'm reading too much into their statements on abortion safety, consider the following remarks which relate directly to the context of illegal, low-resource abortions:
- In some situations of formal illegality, women can still obtain safe abortions. (6)
- Legal authorization is… [an] insufficient remedy for unsafe abortion. (11)
- Where mifepristone is not accessible, various misoprostol-only regimens are being used... its widespread use in countries with restricted abortion laws appears to be associated with reduction in maternal morbidity and mortality. (122)
- Even in developing countries with restrictive abortion laws, increasing use of MVA (manual vacuum aspiration) and medical abortion methods has reduced abortion-related mortality. (135)
- Induced abortion is an impressively safe procedure, particularly but not exclusively where it is legal. (224)
- Medical abortion can expand access to safe abortion care, especially in restrictive or low-resource settings that lack other safe options… Using medications to induce abortion can lower costs and transfer control from the clinician to the woman. Empowering women may be particularly important where large social gaps exist between patients and clinicians, as is often the case in low-resource settings and where abortion is legally restricted and socially stigmatized. (320)
- … nonvaginal routes of misoprostol administration may be preferable where a woman must maintain utmost secrecy about having sought an induced abortion. (321)
- That misoprostol can be administered either in the clinic or in a different location of the woman's choosing enhances her ability to ensure privacy. (322)
- Practitioners with MVA skills can treat most medical abortion complications privately in their own clinics, which is highly desirable in restrictive and remote practice settings. (322)
- …vacuum aspiration is safer, less expensive, and more acceptable to women than sharp curettage. (322)
- … manual vacuum aspiration is equivalent to electric vacuum aspiration in terms of effectiveness, safety, and acceptability for first-trimester abortions. (323)
- [Manual vacuum aspirators are] portable, inexpensive, reusable, and do not require electricity. (323)
- The technique of dilation and evacuation may be adapted for settings that lack laminaria and electricity. Cervical preparation with buccal misoprostal followed by evacuation with MVA and forceps was shown to be safe and effective for women seeking pregnancy termination at 13 to 18 weeks' gestation. (324)
- According to the WHO, "Providing adequate pain management does not require a large investment in drugs, equipment, or training…" (325)
- Effective infection prevention need not be costly or difficult. (326)
- Antibiotics are recommended at the time of aspiration abortion to decrease the risk of postabortal infection. However, lack of antibiotics should not be an obstacle to care; where antibiotics are not available, safe abortion care can still be provided. (326)
- In legally restrictive settings, (safe) options may still be available for women… (327)
In other words, it is not legality that made abortion relatively more safe for the mother, it is the advent of suction aspiration, the use of drugs like mifepristone and misoprostol, and improved methods of dilation. And guess what that means? It means it is dishonest to assert that though abortion is morally objectionable, it must remain legal for the sake of (born) women's health. And lest you argue that in the absence of legal protection, the resources necessary for a "safe" abortion would be unavailable, consider these final remarks:
- For more than 60 years in the USA, dilation and curettage (D&C) with either a sharp or vacuum curette has been the treatment of choice for early pregnancy loss. (267)
- Vacuum aspiration to evacuate a failed pregnancy in the first trimester is performed in a fashion similar to first-trimester pregnancy termination. (268)
- When used in combination, [Mifepristone and misoprostol] are highly effective at terminating a pregnancy up to 63 days' gestation. These same drugs have been studied for treatment of first-trimester pregnancy loss as has the combination of methotrexate and misoprostol. (269)
- D&E for the indication of fetal demise is performed in the same way as D&E for second-trimester pregnancy termination. (272)
The resources and equipment used for elective abortion are the same that are used around the globe in the aftermath of spontaneous abortion care (miscarriage). This means that any physician willing to circumvent an anti-abortion law, would already have the equipment necessary to do so. And as the NAF points out in their remarks on securing safe abortions in a legally-restrictive context, medical abortions can be carried out almost entirely by the woman herself. I point all this out not because I wouldn't grieve just as much over illegal abortion as I do over legal abortion, but because I'm tired of the safe/legal hypothesis being used as a moral trump card. If you support abortion rights, have the integrity to do so without making appeal to the supposed apocalyptic threat illegal abortion would pose to women's health. You can't have it both ways. If abortion is as safe and easy as the NAF wants us to believe, then it's time to give up the pretense that, right or wrong, legal abortion is a pragmatic necessity. Until we do, we'll never be able to examine abortion in an honest, objective light.
Michael Spielman is the founder and director of Abort73.com. His book, Love the Least (A Lot), is available as a free download. You can also find him on Facebook and Google+. Abort73 is part of Loxafamosity Ministries, a 501c3, Christian education corporation. If you have been helped by the information available at Abort73.com, please consider making a donation.