Wednesday, December 26, 2012


When I came out as an atheist almost 3 years ago, very few people were surprised or upset. Whether it was because I’d made efforts warn those who might take the news poorly or because I made clear that I was not trying to convert anybody to my position, I ultimately didn’t catch much flack for a decision I thought would be controversial. I imagine I’ll get a slightly different response from this note. I am coming out of the closet as a future abortion provider. On the one hand, this should not be surprising: I’m openly pro-choice, I’m an unabashed feminist, and I’ve been leaning towards a career in OB-GYN for quite some time. On the other hand, coming out as a future abortion provider increases the chances of being killed for my profession. Many providers take great pains to protect their personal safety, purchasing their homes with corporate shell companies, carrying weapons in public in response to death threats, and fighting to keep their information from being disseminated by pro-life extremists. I feel the need to come out as a “future abortion provider” however, because I fear that vacating the rhetorical battleground only strengthens those who would ban a woman’s right to choose. We have seen a radicalization of Republican politics and policies which explicitly seek to deny access to contraception, target abortion providers for pseudo-scientific and medically unnecessary reasons, and ban abortion even in cases where the life of the mother is seriously endangered. Given the sheer volume of factually inaccurate information readily available—and actively peddled by anti-choice activists—I feel compelled to at least make an attempt to spread the truth about abortion, even if doing so makes me an easier target to violent radicals. But I want to abandon the marketing and rhetorical spin that sometimes clouds these debates. I don’t care if you think I’m a terrible person, and will make no effort to convince you otherwise. I want to head off any ad hominem attacks by simply agreeing to accept any personal smears as irrelevant to the debate at hand. If it makes you feel better to call me a “baby killer” or participating in “genocide,” I’m fine with that. But know that I feel an equal and opposite open disdain for those who would make abortion illegal. Let’s just agree that personal rage is simply not a cogent argument. Although the debate around abortion often centers on the exceptions, I feel passionately that abortion is moral and should be legal at any stage before viability. Although there should absolutely be exceptions for rape, incest, and “health and life of the mother,” too many social liberals have allowed the line to be pushed to these few exceptions, and have neglected to win hearts and minds for common, elective abortions. This has led to nut jobs on the right trying to turn a blanket ban on abortions into a respectable position. Let’s start with the science. About one half of all pregnancies end in spontaneous abortions. Many women who have these abortions are not aware that they’ve even had a one. I start with this point first because I think it fairly roundly destroys the sentimental religious supposition that every embryo is endowed with a soul, and that this soul is non-transferable to a different body, should the mother choose to abort. God didn’t design a very good system for supplying souls with bodies, if he has no b-plan for when an embryo fails. If you really believe that every single embryo is divine, take it up with God before bothering me. The next important statistic is that giving birth is 14 times more dangerous to a woman than getting an abortion is ( ). I’m willing, but frankly not terribly interested in debating the science on this as if it were under dispute. There are any number of reasons why becoming pregnant can be very dangerous to a woman, including increasing the chance of fatal blood clots, massive blood loss, or preventing her from taking required medications like anti-epileptics because of feared possible effects on the growing fetus. Abortion also poses some health risks, including sepsis, bleeding, and perforation of the uterus (in mechanical modalities), although they are clearly far less numerous and less extreme than those commonly associated with pregnancy. If any of you are interested in or confused by anything you’ve heard about the dangers of pregnancy or abortion, shoot me a message and I’d be happy to parse it in public or private, or send you to other sources which you can trust. The obvious retort to this line or reasoning is to focus on the fetus. In 1,000,000 theoretical pregnancies, we could save 634 women by aborting all the pregnancies, but we’d be killing 1,000,000+ fetuses to do so, would we not? The fact that there’s no easy, bumper-sticker-length answer to this question is probably why public opinion on abortion has not been liberalizing in the same way that attitudes about gay rights have been doing in recent years, and that racial attitudes have been doing for decades. Before I try and explain my answer to this argument, I need to head off yet one more frequent ad hominem attack. While I believe that all life has some value and should be respected, I also strongly believe that quality of life should have equal consideration with quantity. This is not to say that I’d barter human lives for fiscal gain or genetic social hygiene a-la Nazi Germany, but I also don’t think that Nazi Germany’s manifold crimes should force us into a patently absurd sentimentality which values any and all hypothetical lives above all other considerations. To my friends who call abortion “genocide,” I would submit that you’re cheapening the term and confusing the issues. Gassing adult gypsies is a far cry from allowing a woman to not carry to term a fetus which has less than a 50% chance of survival anyway. It’s mostly because of this that I don’t see the definition of human life as being the ultimate trump card in the abortion debate. Fine. I’ll admit—even if only for the sake of argument—that a zygote is a full human being. That still doesn’t mean, however, that a pregnant woman can’t morally and ethically decide that she doesn’t want to carry that full human being to full term. Imagine a woman who finds out at the 20-week scan that her child has gross physical deformities which will prevent it from living more than a few days past birth. Should she carry that child another 20 weeks so that the child can experience life for 72 hours? What if those hours are miserable? What if those additional 20 weeks greatly jeopardize that mother’s life? What is the rubric to determine just how much value that child’s life will have, and how do we decide whether it’s worth the costs and risks? I picked a deliberately difficult case to illustrate the point that this IS NOT an easy question with a pat answer, even if we start with the supposition that a 20-week fetus is as human as you or I. Some women in that case would surely want to carry the fetus to term. Others might choose to abort. Yet others might decide to carry the fetus, and then reconsider if a major health concern like preeclampsia came to bear later in the pregnancy. As a society, we have the ability to pass laws and regulations. When faced with the difficult question of abortions, the first question is rather broad: do we allow women to make her own decision about whether she wants to incur the risks and costs of continuing a pregnancy, or do we intervene and restrict or mandate her decision for her. In analyzing (and in talking with a woman in this exact) situation, I am personally uncomfortable with making any decision FOR her. I’d be loath to deny her an abortion if she decided that it would be immoral to force that baby to endure 72 hours of misery. And I can’t imagine being forced to perform an abortion on her if she decided that she wanted to keep her pregnancy. While I can see the theoretical ethical arguments for all cases, I ultimately conclude that it’s beyond my pay grade to make a personal, ethical decision for any woman in this case, because it ultimately has nothing to do with me. And this brings up my ultimate bias—that of being a future physician. Abortion is only one of many ethical questions that I face daily in learning to practice medicine. And, while society occasionally debates these questions in a public forum, medicine already has its guiding principles laid down in our profession. These are: beneficence, non-malfeasance (“first do no harm”), respect for autonomy, and justice. In my view, refusing an abortion to a woman who wants it violates at least the first three of these without question, and the fourth is a debatable point. Given that pregnancy is more dangerous than an abortion would be, I feel it’s a gross violation of medical ethics to force a woman to accept risk to her health against her will. While there are a few points of clarification I’ll get to in my next paragraphs, my point with bringing up the Hippocratic Oath is merely to make the argument that no doctor should consider themself a doctor if they are violating these standards. I feel it should thus be illegal for a physician to refuse a patient an abortion (or a referral to a competent provider). Where the law sometimes provides cover for physicians to refuse, I would submit that these doctors should have their licenses revoked, just as they would be if they violated medical ethics in other situations. There are two arguments I’ve heard repeatedly as assaults on this ethical stand: that the life of the child outweighs any non-mortal costs the mother might have to pay, and that the child is innocent of its conception, and thus has moral standing to demand the costs the mother might pay. The first claim is roundly defeated by medical tradition and laws currently in place. We could easily save hundreds of people today by mandating that every person donate blood or a kidney. Although transplantation medicine is complicated, odds are very good that if we took a kidney from you right now, that it could be implanted into someone with failing kidneys and extend their life for decades. Aside from the cost of the surgery and recovery, it’s likely that your life would not be significantly reduced. And yet we have no such laws. We value your freedom to not undergo forced surgery as being more important than a person with kidney failure’s life. The risk to your life—and the violation of your autonomy—is more important than the guaranteed life of someone else. If only 634 people out of 1,000,000 kidney donors would die in saving 1,000,000 children in need of kidneys, would it be kosher to pass a law mandating it? The second is related to the first, but demands that in some circumstances, that you would owe it to someone else to undergo that surgery. But where is that line? Let’s imagine that you purposely stabbed a family member in the back (literally) and destroyed both of their kidneys. Would it then be moral to forcibly take one of your kidneys and give to that family member? What about if you accidentally got into car accident with them and their kidneys were destroyed? These are tough questions. I’m not sure I have good answers for them. But neither am I convinced that they have any place in our laws or traditions anywhere. The opposite of this ethical claim, however, does have a large precedent. Where else do we refuse to treat a patient if they “deserve” the outcome of their mistakes? When we find someone unconscious on the ground, should we look around for clues as to whether they deserved what they got, before starting CPR (did they look both ways before crossing the street)? If someone has a heart attack because they are obese, should we require an exercise log to determine if they deserved the heart attack, before beginning treatment? What if someone gets a sexually transmitted infection? Chances are pretty nearly 100% that they would not have gotten that infection had they properly used a condom, yet we regularly treat these infections. Indeed, I think the notion of refusing treatment for a patient based on a moral judgment is a path we do not quickly want to go down. While society could clearly mandate more laws to punish people by refusing certain medical treatments (no removal of gangrenous feet due to uncontrolled diabetes), a physician’s perspective chafes wildly at being a form of executioner for the moral majority. It’s one thing for society to not pay to correct the mistakes of others, but it’s entirely different for society to ban treatment because it believes that illness is a just punishment from God. Society does ultimately pay for the mistakes of its citizens, whether in lost productivity or expenses on its balance sheet. We can and should aim to correct and provide incentives to citizens to act responsibly. But forcing them to suffer for their sins when a remedy is available is a virulent form of Christian theology that should not be allowed to gain purchase as public policy. If you want to scourge yourself for your carnal sins, go right ahead. If you want to pass a law that forces us all to do the same, don’t regulate that I have to do the whipping for you. I’ve done dozens of hours of research over the years on abortion statistics and controversy. While I’ll happily parse the statistical nuances of any study you find convincing, it wouldn’t be influential or useful to throw endless statistics at you and expect them to be persuasive. Part of the problem is that both sides of this debate have their own facts and statistics, and the debate about which side is trustworthy quickly eclipses the debate on the issues. So we’ll start with a few (hopefully) non-controversial statements: Making abortion legal and available increases the number of legal abortions. When medical abortion is not legal, some women will seek other ways to end their pregnancy. In both of these sets of women—those who have babies they would prefer to abort, and those who abort using coat hangers—fatalities for the women will be higher than they are where abortion is legal (and thus safe). I thus conclude that laws which prevent abortion will always kill women. For this reason, I chafe at the term “pro-life” for those who oppose legalized abortion. Yes, you’re pro-fetal-life, but that necessarily connotes the deaths of some number of unwilling women. As a future abortion provider and medical practitioner, I’m very much aware that I’m aiding in ending the lives of many fetuses. I’m not the one deciding to kill them, however, so I consider myself free of any sin. Those who support abortion bans are at least partly to blame for forcing women to die as a result of them. So how do we mediate this conundrum? How many fetuses equal one pregnant woman? If you’re passing a law dictating how I do my job, what is the threshold for the health of a woman which dictates when an abortion would be acceptable? Is a ten percent chance that the woman will die enough to justify your blessing to allow an abortion? Fifty? Perhaps such questions are unfair. I sure as hell can’t answer them. As a self-professed libertarian, I don’t think these are questions any government should answer for a woman. Radical as it sounds, I believe that a woman should be the only person who decides what is best for her medically. I’ll be happy to advise her and give her the information she needs, but I deem the “pro-life” laws to be nanny-state government at its worst. To any “conservative” who supports banning abortion, know that you violate the conservatism and the small-government rhetoric you espouse in the worst possible way. I don’t really expect that I’m going to convert anybody to accepting that abortion should be legal. I was religious for long enough to know that reason and logic have no power to dislodge any belief that was arrived at through non-logical means. I do hope, however, that starting this conversation will help people to gain a more nuanced view of the difficult questions which abortion laws address. Far too often I get “I don’t believe in abortion because it’s against my religion” as if that were an answer. Fine. Your religion bans abortion. That is a great argument that your religion is a horrible institution which needlessly endangers women and seeks to enforce its precepts with the force of law, but not a very good argument about why YOU support banning abortion even in cases of rape or incest (or why you’d vote for a congressperson who does the same). I have quite a few friends who are vegetarian and vegan. While I have nothing but respect for their views, I personally think it’s appropriate and even enjoyable to eat meat. I’ve never felt threatened, however, that vegetarians would rise up and pass laws against eating meat, much less that they’d try to close down slaughterhouses, bomb butcher’s shops, or kill producers of veal while they’re in church. If you’re opposed to abortion, do your best to convince people that abortion is wrong. Pass out Bibles in front of clinics. Talk your daughters in to keeping their illegitimate children. But please don’t ban it for everybody else. Don’t pass laws which arbitrarily make abortions harder to get or needlessly expensive. Or at the very least, don’t ask me to respect you when you do.


Mom said...

Isn't hopping into bed with a guy a decision? Don't our decisions have consequences? Shouldn't we all be resposible for our decisions?

Josh Daniels said...

Interesting timing on the big announce, not sure if that was intentional or just a by-product of circumstance given more free time to write during a holiday period.

If you are leaning toward ob-gyn and are an unabashed feminist, then we should definitely talk sometime! My wife has a lot of views on the way society unfortunately has assaulted women by turning pregnancy and childbirth into a disease of sorts and how pop culture makes pregnancy and childbirth into a terrible, scary, painful, or loathsome thing. I think this sort of castigating of childbearing demeans women because it takes something fundamental and unique about them and attempts to denigrate it. [My thoughts are completely unrelated to abortion--I'm not really interested in having that debate since I think our policy on abortion in this country is unlikely to change much one way or another--its more of a political football that allows both parties to score points with salient parts of their base]