Abortion: Can We Please Talk about it? Please?

I’ve seen this from so many sides. I’ve been yelled at as a politician, I’ve delivered babies as a doctor, and I’ve investigated deaths of infants as county coroner. But none of this makes my perspective more valid than yours. Most important, I have never had a life growing inside my body, dependent on me for its growth and existence. The emotional and personal aspect of this public policy matter makes the discussion difficult. If we cannot talk with each other about the stories we have, the values they reflect, and the goals we have for our society, how can this society of 300 million function as a representative democracy?

Since the Supreme Courts divided Roe v Wade decision in 1973, state legislatures, interest groups and political parties have lined up on one side or the other. Every country in the world has laws limiting the performance of the act of destroying a growing life within the body of a nurturing mother. The balance of when the mother or the growing life has authority is the crux of all these laws. My perspective is reflected in the stories I remember.

After four years of medical school that included embryology and anatomy, I went off to a three year residency training to become a family doctor. Most of the rotations are mandatory, but there is some room for electives. I remember being asked if I wanted to learn “terminations” as a procedural skill. I deferred; I wanted to deliver babies and work in a small town. I didn’t believe a small town could accept that dichotomy, and I wondered if I could.

The residency I chose was known for its excellent obstetric training. Residents worked with two perinatologists who handled most of the high risk obstetrics for a large area. We participated in the management of these complicated cases, learned the surgeries and medicines and saw the issues up close. We also worked with low risk cases and our own patients. It was excellent training for a family doctor planning to do obstetrics in a small town.

Marilyn was a young woman, acting even younger than her late teen years from a small town north and west of us. She was referred to us because her pregnancy was very complicated. She came from a narrow religious background but her family had cut attachment since her baby was conceived out of wedlock. She had a close friend, older than her and more assertive but of the same faith community who attended and advised her. Marilyn was a juvenile diabetic. That alone made her pregnancy high risk, but by 20 weeks gestation a severe brain fetal anomaly had been detected. It was not considered to be compatible with independent life. On top of this, as her gestation progressed she developed pre-eclampsia a condition that puts the mother’s life at risk.

She was a quiet gentle soul. I remember the friend more; she often spoke for Marilyn on our twice daily hospital rounds. I was never present when the option of “termination” was discussed, but I was told the community family physician and the consultants had all offered the option. “She wants the baby; though she knows it cannot live. And her friend wants the baby for her.”

We did our best to control her blood sugars as she stayed at bedrest in the hospital for weeks, but her blood pressure rose and her kidney function started to fail, so early delivery was recommended. After two days of a difficult induction of labor she came to complete cervical dilation and strong contractions but could not deliver vaginally.

The attending perinatologist I was working with that weekend had practiced in a South African hospital where thousands of babies were delivered monthly, many brought from distant villages in the backs of Toyota pickups in severe distress. There were more maternal mortalities at that hospital in a month than our state experienced in a year, and infant mortality had a similar proportion. I remember his downcast look as we prepared for surgery. “We are going to put her life at even greater risk with this surgery for a non-viable fetus.” Further, once the surgery was started, we had to use a classical incision in the uterus, putting any future pregnancies into greater risk.

She survived, though I know nothing of her life after she left the hospital. The baby did not breathe at birth.

Twice in my small town baby-delivering career I delivered infants with malformations incompatible with life. The first time it was a healthy mid-twenties woman who had hid her pregnancy until near term. She delivered the fetus spontaneously at 38 weeks with no complications, but it did not breathe at birth. The second time it was a mid-thirties mother of three. The malformation was detected by ultrasound at 30 weeks when fetal growth was lagging. She wished to terminate the pregnancy, not carry it to term. This choice would now be illegal by Idaho law, even though that law has been held unconstitutional. She also delivered a fetus that did not breathe at birth. If causing a woman to deliver a non-viable fetus before term is illegal in our state, what should be the legal status of not attempting resuscitation of such a fetus? Is this something we can talk about?

 

In my first few doctor years in town, I reluctantly accepted appointment to the public office of county coroner. I believed the investigation and determination of the cause and manner of death was an extension of serving the health of my community. But this dichotomy of serving life while attending deaths stretched my patients’ limits of acceptance and I got lots of teasing humor, and some sharp criticism.

The call came midmorning from the city police to respond to a death behind a college dormitory. It was a sunny fall day and only eight blocks so I rode my old Schwinn one-speed. On the way I imagined a student falling or a suicide since the college semester had begun and our community has seen such tragedies. But I was led to the back of the tall building near the industrial dumpster and shown the bloody body of a dead new born infant. A young woman was being questioned after a house keeper had noticed blood and checked the refuse.

She had hidden her pregnancy, no classmates knew, nor her family. The cause of death was asphyxia, but whether the baby died from the mother’s act of intentional suffocation or inattention or bungled attempts at resuscitation I do not know. I listed the manner of death on the death certificate as homicide, but the coroner is not the prosecutor, the judge nor the jury. She pled guilty to involuntary manslaughter and was not incarcerated.

Justice is a goal and I believe no fixed formula makes the effort pure or true. But admission of guilt and reparations for those wronged fits into the calculation. When a life is taken, what reparation can be given? Some have a ready answer. I do not.

There was another child killed by its parent in my time as coroner. Such is a rare occurrence; infant homicide happens 2-5 times a year in our state. But the incidences of abuse and neglect are probably 100 times that. Do numbers tell a story?

Elective abortions in Idaho have declined in both rate (number of abortions per 1000 women age 15-44) and total number for the last seven years. This may be a reflection of the national trend, which is also declining, or the reduction in abortion providers available. Approximately a third of the abortions are performed in surrounding states, but these are reported and counted nonetheless. Or the decline could be a reflection of the increased availability of birth control and education. Colorado carefully studied the rate of abortions when they made long acting birth control readily available and they saw abortion rates drop by almost half.

I tried debating against a 20 week abortion ban on the floor of the Idaho Senate by referring to these numbers. I pointed out how Idaho’s abortion rate is about a third of the national rate and declining. I believe Idaho is doing a good job with the goal that abortion be legal, safe and rare. The floor sponsor told a story of looking at his new baby grandson then argued that even one abortion was too many. The bill passed and is still on the books, though found unconstitutional in Federal Court. Stories persuade; policy discussions don’t. I am not sure how long we can rely on the courts to hold this stance if we are not prepared to tell our stories about this issue.

Simple answers are attractive. Many believe a strict prohibition, even criminal penalties against the woman carrying the embryo is a way to accomplish their goal. And what would that goal be: Justice? Prosperity; that all children lead healthy, productive lives? Or is the goal the elimination of all abortions? Prohibitions have been tried; they did not accomplish this goal. Murder is prohibited and prosecuted, but it is not eliminated. In my years in the Idaho Senate I saw many attempts at laws nibbling at the corners of prohibition on abortion. Idaho passed a “Fetal Pain” statute that would have banned all abortions after 18 weeks gestation. We debated a mandatory ultrasound bill, and passed laws to require women to be counseled according to written laws.

As a physician, I have never seen a woman be cavalier in this consideration. As a coroner, I always wondered about the thinking of a person that would kill a child. As a State Senator, I never thought I could fashion a law that would advance the humanity of a child murderer, but I was quite comfortable that statute defined the consequences for such an action. Neither did I believe I could craft a law that would make a mother choose the right path for her and her embryo or fetus. I was always amazed at the hubris of my colleagues, that they thought they could know best what a woman should choose for herself, her child, her body. The life of a fetus should be protected if it could live without the support of the mother’s nurturing body, but before that line is crossed, the law is a poor substitute for a nurturing mother’s judgement. Indeed, the laws we pass can be more like an abusive parent when they are wielded without compassion. Lawmakers should strive to make all life prosper; such a goal requires wisdom and balance, not absolutes and edicts.

We are going to need to talk about what our goals are for each other, for our state and our nation. Tell your stories. Listen to theirs. Then have the courage to advocate.

About ddxdx

A Family physician, former county coroner and former Idaho State Senator
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