Abortion: I. Medical Perspectives

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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, and the current era is no exception.

People interested in the ethics of abortion turn to medicine and medical practitioners for the following sort of information and perspectives, which will be considered in this entry :

  1. whether medical knowledge clarifies the moral status of the fetus as a human being;
  2. whether medical information on abortion confirms it to be safe for the woman;
  3. what the medical perspectives are on performing early versus late abortions, particularly in light of controversies regarding partial birth abortion;
  4. 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, medicine has never had the ability to establish 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. Similarly there is disagreement among some physicians over the moral status of the fetus and the permissibility of abortion.

There is some 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. Here, viability is not the key point. Rather, any termination of a pregnancy by medical or surgical means is termed an abortion, regardless of the stage of the pregnancy.

Safety and Harm for the Woman

POSSIBLE PHYSICAL HARM. There is a close tie between medical information on 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).

As of 2003, induced abortions performed within the first twelve weeks of pregnancy are among the safest and simplest forms of surgery and, based on maternal mortality ratios (number of deaths per 100,000 live births), both firstand second-trimester abortions, when performed by properly trained personnel, in general are safer than carrying a pregnancy to term (Cates and Grimes). 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 since a basic tenet of medical ethics is to avoid harm.

The major immediate complications of induced abortion, listed in order of frequency, are infection, hemorrhage, uterine perforation, and anesthesia-related complications. Overall complication rates for legal first-trimester abortions are less than 0.5 deaths per 100,000 abortions performed (as compared to more than four per 100,000 in the early 1970s, before the U.S. Supreme Court decision Roe v. Wade [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%) done in the United States are performed within the first twelve weeks of pregnancy, when abortion is safest. More serious complications may occur in procedures done later in pregnancy.

ABORTION PROCEDURES. Information on abortion procedures often sheds light on questions of safety as well as on other aspects of abortion that are relevant to ethics. The most common early-trimester abortion procedure (done between seven and twelve weeks' gestation) is suction curettage, in which a thin plastic tube (canula) is inserted through the cervix and, by negative pressure vacuum, the contents of the uterus are aspirated. Usually, following the aspiration procedure, a curettage (using a sharp, spoon-shaped surgical instrument, a curette) is 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. General anesthesia is considered by many to be an unnecessary additional risk, since local anesthesia, injected into the cervix, often is quite effective (Grimes et al.). 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), which uses specially designed forceps in conjunction with vacuum aspiration to facilitate the removal of the uterine contents. Prior to initiating the procedure, the cervix is dilated gradually over a number of hours using sponge-like materials that expand as they absorb local cervical fluids. Though still considered a minor surgical procedure, D&E is clearly 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, making the procedure more risky. The D&E procedure can be performed in free-standing clinics, but often ambulatory surgical services in a hospital setting are chosen for the 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 that the various methods of abortion be discussed as well as the possible anesthesia alternatives.

The other abortion procedure used fairly commonly in the second trimester is instillation abortion, in which a solution instilled 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. More 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, or retention of placenta, and 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 carried out 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 works by blocking progesterone production by the ovaries, an essential hormone in the early stages of pregnancy and in the 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 U.S. Food and Drug Administration (FDA) approved RU–486 for use in the United States, and it has been distributed since the following November by Danco Laboratories, LLC under the brand name Mifeprex. According to the guidelines set forth by the FDA, it 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 visits are necessary for this medical means of pregnancy termination: the first to make the diagnosis and to give 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 since a one-week delay between the diagnosis of pregnancy and the initiation of an abortion procedure is mandated.

As a result of the requirement for three visits (or four in France), because there may be a few days before the abortion occurs and as many as ten or more days of vaginal bleeding thereafter, and because it may be more expensive than surgical abortion, many women in France and the United States still prefer suction curettage as their method of choice (Kolata). However, there is anticipation that as awareness grows, many women will still 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 clinic facilities.

Successful termination has been shown to occur in 97 percent of patients using the RU-486 regimen, with the remaining patients requiring 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 because the procedure was incomplete. Most women develop strong cramping after taking the prostaglandin (because the drug induces uterine contractions) and usually have the abortion within a few hours after receiving prostaglandin. In France, RU-486 is therefore provided only through clinic facilities and in this setting, the abortion often occurs during the same 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 who has made arrangements to provide such care through others.

While studies have demonstrated the safety and effectiveness of RU-486 as a morning after pill for use after unexpected midcycle intercourse (Ashok), preparations containing the same hormones as are 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 (ECPs) and the IUD are more 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. The majority of abortion procedures in the United States are provided by obstetrician-gynecologists, with a small percentage performed by other providers such as family practice physicians, midwives, or nurse practitioners. 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 ob-gyn 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, over the last decade 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 ob-gyn residency programs to include family planning and abortion training for its students, though abortion is generally still presented as an elective part of training. The impact of these requirements was demonstrated in a survey conducted by the National Abortion Federation (NAF). The investigators of the NAF report found that from 1992 to 1998, ob-gyn residency programs reporting routine first trimester abortion training increased almost fourfold, from 12 percent to 46 percent, and routine second trimester abortion training from 7 percent to 44 percent (Almeling et al.).

Finally, 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 this service. In response to the escalating violence, Congress enacted theFreedom of Access to Clinic Entrances Act, or FACE, in 1994. This statute established federal criminal penalties and civil remedies for violent, obstructionist, or damaging conduct affecting reproductive healthcare providers and recipients, and 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 as well as 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 PREG NANCIES. 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 that of 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, the so-called postabortion syndrome does not meet the American Psychiatric Association's definition of trauma (Gold).

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., p. 42). Former U.S. Surgeon General C. Everett Koop, 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 postabortion syndrome and that emotional problems resulting from abortion are minuscule from a public health perspective" (Human Resources and Intergovernmental Relations Subcommittee of the Committee on Governmental Operations, p. 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 failure to recognize (or denial of) pregnancy. A smaller percentage of these later abortions occur because of 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 the medical profession's knowledge of and attitude toward the stage of development of the fetus, interacting with local cultural, religious, and legal ideas and beliefs. Together, these factors have had a significant impact on medical practice. Medical practitioners often have more difficulty with late abortions as compared to earlier ones, because the procedures are more difficult to perform in late abortions, because of the more advanced state of fetal development, and because of the political climate surrounding so-called partial-birth abortion.

Prior to the latter half of the nineteenth century, abortion was 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 prior to quickening, for it was only this detection of fetal movement that confirmed the existence of a living human fetus. There is little in the historical literature that describes how physicians in that era actually felt about abortions, although based on the information discussed below, 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's Principles of Medical Ethics permit physicians to perform abortions, provided they are done in accordance both with the law and with good medical practice (Council on Ethical and Judicial Affairs, Opinion 2.01). In general, for the last 100 years or more, and especially since the U.S. Supreme Court decision in 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 and there has been general agreement that late abortion is permissible in those cases where 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, so the medical profession has shown a reluctance to perform abortions later in pregnancy, even early in the second trimester. In addition to new 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 current 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 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 do 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, as discussed earlier, 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 minimalization of harm to the fetus.

Most recently, the debate over partial birth abortion has presented significant challenges to physicians, other providers of abortion services, and proponents of a woman's right to choose to terminate a pregnancy. While legislation to ban this procedure has been proposed and debated in Congress, in several state legislatures, and finally in the Supreme Court, 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 has resulted in the failure of these bans to be constitutionally upheld (Annas, 1998).

In March 1995, the first Partial-Birth Abortion Ban Act was introduced in the U.S. 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 Clinton vetoed the bill because of its failure to include an exception allowing the procedure to prevent serious, adverse health consequences to the mother (Remarks on Returning without Approval to the House of Representatives Partial Birth Abortion Legislation, pp. 643–647); he vetoed a revised bill in October 1997 for the same reason (Message to the House of Representatives Returning without Approval Partial Birth Abortion Legislation, p. 1545).

Over the interim between the two bills, medical organizations took conflicting positions. In contrast with 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, one method of terminating a pregnancy after sixteen weeks' gestation and specifically involving "1. deliberate dilation of the cervix, usually over a sequence of days; 2. instrumental conversion of the fetus to a footling breech; 3; breech extraction of the body excepting the head; and 4. partial evacuation of the intracranial contents of the living fetus to effect vaginal delivery of dead but otherwise intact fetus" (ACOG p. 2). While the committee could identify no specific circumstance where this method would be the only option to preserve the health of the woman, they stated that "only the doctor, in consultation with the patient, based upon the woman's particular circumstances can make this decision" (ACOG, 1997, p. 3).

Similar laws have since been passed in more than two dozen states and found unconstitutional; the most significant decision was issued by the Supreme Court in a challenge to Nebraska's Partial-Birth Abortion law in the case of Stenberg v. Carhart in 2000 (Annas, 2001). The case involved Dr. 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 are 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 v. Casey) because it was written so broadly as to ban not only the rarely used dilation and extraction (D&X) procedures but also dilation and evacuation (D&E) so commonly used to terminate pregnancies even early in the second trimester. Ultimately, the Stenberg decision reinforced the important position that decisions regarding how abortions can most safely and satisfactorily be performed should be made by women and their physicians.

Public Health and International Perspectives

Abortion is widely available with varying restrictions throughout the industrialized world. In recent years, 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 first-trimester 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 (WHO), as many as 100,000 or more maternal deaths occur each year as a result of complications of an unsafe, usually illegal abortion. Even in the United States, some illegal abortions continue to be performed in cases where 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 the complex issues relating to the reproductive and autonomy rights of women versus the rights of the fetus, suggest the continuing importance that must be given by the field of bioethics to abortion, particularly to the question of 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.

sara iden (1995)

revised by anne drapkin mlyerly

SEE ALSO: Embryo and Fetus; Fertility Control; Reproductive Technologies; and other Abortion subentries


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