Abortion from a doctor's perspective  

Monday, September 8, 2008

By David Katz, MD

The topic of abortion will rear up in rhetoric, and between its lines, throughout the presidential campaign now underway in earnest. It will reverberate in public policy after the votes are counted.

And so I confront this polarizing topic with equal measures of trepidation and resolve to state:

I am emphatically pro choice.

And I am just as emphatically anti abortion.

The first statement from a public health physician with public policy leanings left of center should come as no great surprise. The second might surprise--but shouldn't. It is the second side of the same position. No one is for abortion, least of all the women who resort to it.

I know such women. They are among my friends (and perhaps yours), my family (and perhaps yours), and my patients. No one of them is for abortion. Each of them confronted it as a last resort. Some with equanimity. But some made the most anguished decision of their lives. And some have dreamt in troubled agitation ever since of that life that might have been. (Find answers to your pregnancy questions here).

Yet few would revisit the decision, even after the clarity of retrospection, and the filter of patient reflection. The regret that derives from a last resort is not resorting to it, but needing to; being left with no better options in the first place.

The moral debate over abortion is, in fact, an insoluble distraction. On the one hand are compelling arguments about autonomy, on the other, compelling arguments about competing autonomies, and the sanctity of life. Both sides of the argument inspire passions, but neither persuades. In the end, the war of words is internecine; everyone loses. An opportunity for unified purpose and unified progress is squandered.

Those, like me, who are pro choice might cite the principle of autonomy--that I and I alone should rule the destiny of my very own skin. But ethicists point out that my autonomy is bounded: my right to swing a stick ends where your nose begins. How that relates to the unique dyad of pregnancy, and an entity that is not yet viable on its own, is debatable. The issue of viability, and privacy rights, were central to the 1973 Roe v. Wade decision. But abortion, arguably, puts two noses in play. Autonomy is not an iron clad defense of the right to choose.

The sanctity of life is by no means an iron clad argument against it, either, because it is not a principle we fully honor. We live in a society that sanctions capital punishment, meaning some priorities- punishment among them- trump life itself. The same societal groups that most adamantly oppose abortion seem most adamantly to defend capital punishment, and lethal means of self defense.

We accept that our police are entitled to shoot and kill those who threaten their lives and limbs, and soldiers are entitled to kill those who might pose a threat to our way of life. An unintended pregnancy could very well constitute a far more certain threat to one's way of life than the basis for certain wars.

We even accept, although of course with deep regret, the collateral damage of war--the death of innocent bystanders an ostensibly greater good demands.

The notion that the heavy hands of government might disentangle the delicate stands of this Gordian knot seems very far-fetched. We have historical evidence they can not. When abortion was illegal in the United States, it was nonetheless common--just also unsafe.

According to Planned Parenthood, there are still over a million abortions each year in the United States. That number is much lower than it was during the 1980s and 1990s, but we should be able to agree across ideologies it is too high.

Lowering it will not result from ideology, but rather epidemiology: the public health science of what actually changes outcomes at the population level. Our immediate and common needs are better addressed by data than diatribe.

Whatever changing abortion laws might do to abortion rates, it would do nothing to change the rates of unintended pregnancies, or the transmission of HIV and other sexually transmitted diseases. Posting the Ten Commandments on a classroom wall does nothing at all.

Data show that educational programs that empower girls and convey a sense of responsibility to boys are helpful. Emphasizing abstinence as an option works, too, provided there are contingencies for when it is not the option chosen. Acting as if it always will be is among the most ineffective strategies of all: denial.

Teaching about barrier contraceptive use--condoms in particular--and making such contraceptives readily available is highly effective. And, of course, these interventions are just what is needed to reduce the toll of HIV as well.(Find out why growing numbers of doctors and pharmacists refuse to prescribe or dispense birth control pills).

Current policies in the United States place ideology ahead of epidemiology. Sexual education and contraceptive access are inconsistent; the current administration favors ineffective, abstinence-only instruction. Family planning services are underfunded. Contraception is left uncovered by many insurance policies.

Opposing a desperate remedy while propagating its malady is badly muddled at best, at worst, downright hypocritical. As political positions are debated and policies compete, hypocrisy should not be among the contestants. I dare to hope that whatever our disparate positions, that is a policy on which we all might agree.

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