Abortion: Freedom and Responsibility in the 21st Century
A Roundtable Conversation
Dr. LeRoy H. Carhart, lead plaintiff in the Gonzales v. Carhart Supreme Court case.
Donna Crane, government relations director at NARAL Pro-Choice America.
Ann Furedi, the chief executive officer of the UK abortion provider, bpas.
William Saletan, Slate.com’s national correspondent.
Denise Shannon, moderator and executive director of the Funders Network on Population, Reproductive Health and Rights.
In late February, Catholics for Choice sponsored a roundtable conversation on recent political, ethical, moral and social developments in the abortion debate.
Drawing a parallel to John Muir’s environmental writing that purports everything in the universe is related to everything else, moderator Denise Shannon initiated the conversation with the thought that abortion too is related to a multitude of issues. More than the termination of a pregnancy, she said, abortion relates to sex, women’s rights, politics, medicine, health, health care and developing human beings.
Asked by Shannon how abortion is thought of in a political context, Donna Crane of NARAL Pro-choice America said that in the US, “Abortion is a cultural touchstone—the center of a constellation of issues that range from abstinence-only policies to teenage pregnancy to Internet content. The abortion conversation brings a lot of baggage.” The context of abortion conversations depends on the audience, she noted. You might be talking about abortion, but your audience is hearing a different conversation, such as how abortion relates to the content their kids are accessing on the Internet.
“In the abstract, abortion also is a moral touchstone issue,” explained Ann Furedi of bpas. “The abortion conversation is linked to our attitudes about sex and morality.” Abortion is used as a coded reference to
suggest something is wrong with society, she said, to suggest a need to move back to more careful times.
Will Saletan of Slate.com affirmed that numerous topics swirl around abortion. “When I ask people what abortion is about, everyone answers differently,” he said. Coalitions that form around the abortion issue have different ideas about sex, parental authority, life, religion, the dehumanization of life, sex crimes, medicine, and doctors and how they are regulated.
“Politicians, clergy, and social interest groups have used abortion as a weapon to achieve their goals, from feminists promoting their ideas to those pushing the antichoice agenda,” said Dr. LeRoy Carhart. In the end, abortion is no different as a medical procedure than a radical mastectomy or other life-saving procedure, he said. “A woman has the moral responsibility to bring into the world a child she can care for and who will be a benefit to society,” explained Carhart. “She has the same responsibility to try to avoid abortion and to not bring a child into the world if she is not ready.”
In questioning how to adjudicate among the different abortion coalitions, Saletan noted the significance of Carhart’s statement about a woman’s responsibility. “The choice is up to the woman and so is the responsibility that goes with it,” he said. “Freedom and responsibility are essential, linked concepts, not just freedom alone.”
Abortion and Morality
Treating abortion as a moral issue tacitly assumes abortion is wrong and cannot be present in a morally conservative framework, noted Furedi. Pragmatists say the need for abortion is not preventable so it must be provided. “I look at it in a slightly different way in that there is good in providing abortions,” she explained. “It is morally wrong for a woman to be denied the ability to end an unwanted pregnancy because of someone else’s value system. Women have the right to decide how to exercise their reproductive life choices.”
“We need to reframe the moral discussion so the anti-choice lobby isn’t the only player to occupy the moral framework,” she continued, noting the moral framework must focus on what constitutes a good society, such as justice and fairness. “I want my child to grow up in a society that allows people to have sex without fear of consequences. People should be able to have sex for fun, love or intimacy without fear and with the knowledge that if contraception fails abortion is available as a backstop.”
Asked by Shannon if abortion is something that is part of a good society, Crane said, “The government has the responsibility to leave people alone. In exchange, the people have the responsibility to act well.” She noted, however, that the abortion conversation is affected by the fact that a substantial number of people who say abortion is wrong are well represented in the current political environment.
“The abortion conversation is affected by America’s view of sex and the deeply founded beliefs about morality versus immorality present in our society,” Crane explained, adding, “I don’t think the beliefs need to be mutually exclusive. If someone can be prolife because of religion, why can’t one be prochoice because of one’s faith?” she asked. “Being forced to bear children also should be considered immoral. The prochoice lobby can’t cede morality to the other side.”
In response to a question by Shannon about whether abortion can be immoral, Carhart replied, “Only if someone is forcing the woman to have an abortion. Women know what they can and can’t handle. When women ask for help you need to give it to them. It is immoral to turn them away. When you don’t listen, you find the dumpster babies.” While he encourages women to have their partners with them, he interviews each woman alone to make sure she is there by choice.
“The morality of an abortion decision is up to each individual and takes in the context and nuances of the woman’s situation,” said Saletan. “The woman is best positioned to understand the ingredients of her moral decision.” He noted, however, that not all decisions a woman makes have to be morally acceptable. “Some abortion decisions are more defensible than others,” he said, adding, “Some abortions should be preventable.” For example, early pregnancy kits that can identify the sex of the fetus allow a woman the option of a sex-selective abortion decision, which, he said, is wrong.
While some decisions might make others uncomfortable, said Furedi, the decision is still the right of the individual woman. Another way to look at the sex-identifying kits, she suggested, is that they enable couples to have the child they want. “Discussions about things that make us feel uncomfortable still come down to the context of an individual woman’s life,” she said, noting that as a service provider she would find it impossible to decide when she would deny a woman the right to an abortion. “Even a trivial reason, in the context of a woman’s life,” she said, “often can become much more.”
“I would never argue that women sometimes don’t make wrong decisions about abortion,” Furedi explained, “just as women sometimes make wrong decisions about marriage, jobs or house moves. Abortion doesn’t protect women from making choices they might later regret. Wrong, however, is different than immoral.”
A woman shouldn’t be held more accountable for her decision about abortion than other decisions she makes, said Crane. The fact that she might make a wrong decision doesn’t negate the fundamental point that there isn’t anyone else who can make a better choice. “From the gravest to the simplest decisions,” she said, “one likes to think we do make generally right choices. We need to arm people so they can make the right choices, but shouldn’t fall into the trap that somehow this decision should be held to a higher standard.”
If one believes the woman is best positioned to make the decision, said Saletan, any abortion law that dictates what a woman or doctor must do is wrong. “Categorical judgments are inherently going to be clumsy and counterproductive,” he said. “Passage of legislation might make the lawmakers feel good, but the results are ugly.” How, he asked, do we keep the other side from bringing in the long arm of the law and keep cops and the criminal justice system out of the picture? “I fear a world,” he said, “where we have to choose when the fetus is a person and a baby in a dumpster is a thing. We will end up with a world where people treat babies as things and, out of fear, the public will gravitate to legislation to regulate these things.”
“There is danger in a world where lines are drawn arbitrarily and moral issues are determined externally in an arbitrary and almost random manner,” said Furedi, using late-term abortion as an example. “People argue that late-term abortion is less moral because the fetus looks more like a baby. It is true that abortion stops a beating heart and kills a potential person regardless of the stage at which the abortion is performed. The question is whether or not that is acceptable.”
You could be a pragmatist and say that, according to the fetus, the point in time at which it dies is moot, said Carhart. The fetus either will or will not become a child. “It is more moral for a woman to make a decision at 26 weeks,” he said, “than at 12 weeks if she needs the extra time to make her decision. That extra time is more important than where we draw the line at when abortions should be stopped.” Late-term abortions do not present a safety issue, said Carhart. According to various US studies, between 13 and 20 women out of 100,000 die from being pregnant each year. Statistics show complications from abortions are 700 times less likely than complications from pregnancy.
A woman’s need to have the time to make a decision, said Saletan, must be weighed against the moral fact that over time the fetus acquires and deserves more moral consideration due to biological facts. Because of this, he said, it does make a difference whether an abortion is performed at 12 weeks or 26 weeks. “We need to help women make their decisions as early as possible,” he said, “because what is aborted at an early stage is different from what is aborted at a later stage.”
“The only one who can draw the line is the mother, not science or medicine,” said Carhart, adding, “Some women never feel the baby is alive.” Calling his participation during his residency on an abortion committee that determined whether or not a woman could have an abortion one of the most immoral things he has ever done, he said, “I don’t want to see us go back to that.”
Carhart cited successes in the abortion rate. Last year, 1.3 million abortions were performed out of a child-bearing-age population that was at least twice as large as it was at the time of Roe v. Wade, at which time 1.5 million abortions were being performed annually. The availability of emergency contraception (Plan B) and better access to family health and family planning services also is helping. And, while the number of teen pregnancies
is elevated, he noted that significantly fewer abortions are being performed.
Prevention as a Way to Reduce Abortion
While the abortion rate may be declining, it should not be used as a marker for how things are going, explained Furedi, because the rate can be reduced by prohibiting abortion. “Instead, we need to reduce the circumstance that can cause abortion,” she said, “and understand that women’s growing expectations about what they can do with their lives actually might increase the number of abortions performed.” Everything should be done to reduce the need for abortion, according to Furedi, including finding effective means of contraception and implementing welfare measures allow women to continue a pregnancy if they want. “We want to prevent abortion,” she explained, “but have to accept that can be done only by reducing unwanted pregnancies. I don’t think abortion is the problem. Unwanted pregnancies are the problem.”
The prevention measures provided in reproductive health centers work, said Shannon. Women who don’t have local access to abortion often have to travel to the one or two clinics that provide the service. This is one reason, she said, for the lower rate.
Crane concurred. “The reason for the decrease in the abortion rate is more about low-income women being blocked from services,” she said, noting the birth rate for low-income women who don’t have access to health care is increasing.
Asked by Shannon what should be eliminated to make abortions rare, Saletan said the better question is: What actions could be implemented that don’t involve the criminal justice system or state legislatures? A voluntary counseling system that integrates the people and providers who care about the woman is needed, he said, instead of the current government policy toward counseling that regulates abortion in an unrealistic way.
“Rather than an ad hoc system of doctors deciding what can and can’t be done,” Saletan said, “the process might include a group and individual counseling system with people who know what they are talking about and can help a woman understand her options. The moral fact is that it is better to prevent an unwanted pregnancy and for the woman to make the abortion decision sooner rather than later. Information should not be forced on a woman. Congress shouldn’t be in the position of writing a paragraph that must be read to a woman. We need, however, a formal structure we can tell people about.”
Perhaps the reason it is hard to define a counseling program, suggested Furedi, is that “a panel of experts
implies ordinary people aren’t competent to make decisions. The only person who is competent to make a decision is the woman herself. Only her doctor is capable of deciding with her to carry out the abortion.”
Expressing an unwillingness to give up trying to find a solution, Saletan asked if the moral discussion might be articulated or realized in a way that relieves the pressure on the political discussion.
The difficulty of defining the support system, according to Crane, lies in the manifestation of two realities. “The US health-care system is broken and the avail available services are not consistent,” she said, “and the mental health system is nonfunctioning. As a result, the two areas where women should be able to get help are not available. The fact that they don’t exist is an artifact of the country’s crumbling and pieced-together medical system.”
If a system were in place, asked Saletan, would the people counseling a woman have the right to question her decision, particularly when a woman comes back for a second or subsequent abortion? “Counselors should not have the right to make a woman’s decision,” said Crane.
Furedi replied that her counselors ask women about the effectiveness of the contraceptive they are using, noting that women still define the amount of counseling they receive. “Reasons for why women re-present can be explainable,” she said. “For example, some women are very fertile. Also, a woman who has an abortion at age 16 and re-presents at age 26 is a completely different person. Abortion is not without risk and a horrible experience. The image that women are indifferent to abortions is false. In general, women are highly motivated to avoid abortions.”
Citing statistics that show 47 percent of women presenting for abortion have had a least one previously, Shannon asked why some women re-present.
In response, Carhart said Hispanic women who are Roman Catholic and represent for a second and third abortion say they don’t use contraceptives to prevent pregnancy because the church says it is wrong. “They can receive forgiveness for an individual abortion,” he explained, “but not for the continued use of contraceptives.”
“We should be doing more on the prevention front for purposes of humanity,” said Crane. “Women who are pregnant or fear they are pregnant often are in crisis. In most situations women always have some hesitation about the ultimate decision. Few women are at full peace with their decision. I wonder if those on the other side, when they say they want abortion to go away, really want abortion to become as dangerous as possible so it becomes a punishment.”
“Abortion on demand without apology is not going to fly,” said Carhart. “But I do think the only way to survive the abortion issue today is to not give up the fight and to not be con cerned about the fact that we don’t have many people coming over to our side.”
Prochoice Versus Pro-Prevention
On the political side, asked Shannon, is talk about prevention just a way for politicians to get away with not addressing abortion?
Taking exception to the word “just,” Crane said the prevention discussion is a way for some politicians to avoid the difficult abortion conversation. For others, however, it gives voice to a critical belief they possess that along with the need for abortion to be safe and legal, enough isn’t being done to make abortion rare.
“The pro-birth-control argument is a fantastic argument for preventing abortion,” said Furedi, and a good position for Catholics for Choice to take. “It does worry me, however, that we might inadvertently hold ourselves hostage by promoting contraception as a way to eliminate abortion.” In other countries, she noted, statistics show contraception availability does not reduce the number of abortions. She cited a campaign in the United Kingdom that promoted making emergency contraceptives available through pharmacies as a way to decrease the teenage pregnancy rate. “It didn’t,” she said, adding, “Even when the emergency contraceptive is used correctly, 1 in 200 women will still get pregnant.”
Furedi also expressed concern that prevention does not become an opportunistic strategy that is easier than the
harder, more difficult abortion conversation. If prochoice organizations choose to focus on prevention rather than abortion, she warned, providers could be left exposed. “It strikes me that we could fool ourselves that prevention is common ground,” she said, “when it is common ground on prevention, but not on abortion.”
Crane expressed a need and place for the prevention discussion. “In the United States we can’t have the difficult conversation now,” she said. “If you go to a conservative audience, you can lose the opportunity to have any kind of conversation if you don’t have the choice about where to begin the discussion. You must understand your position as well as that of your opponent. One of our liabilities as a movement is the public’s mixed views about abortion. We either will not have a conversation with them or we will start the dialogue with something with which they are more comfortable.”
Expressing her understanding of the situation in the United States, Furedi reiterated the need to have the more difficult abortion conversation. “We need to have different conversations with different people at different times,” she said. “By second guessing people’s conservative responses we can run behind instead of leading.” As an example, she cited a UK parliamentary committee on science that looked at fetal pain using new scientific evidence. When the investigation started, the prochoice movement worried the results would not be favorable. The report, however, was progressive and more than the movement could have hoped for.
Citing his impression that political pressure from the anti-choice movement has decreased as measured by the number and types of bills in Congress and state legislatures, Saletan asked if the change is due to the lower abortion rate.
Crane replied that the shift in legislation and the lower abortion rate are two different phenomena. More bills are prochoice, she agreed, but noted the change is a function of who is in control of the state legislatures. According to Crane, the abortion rate is not discussed in a political context.
Looking for a way to synthesize rate-reduction measures, Saletan called for a process that would articulate what
prochoice supporters might agree about, such as preventing unwanted pregnancies versus the taking of unborn human life. “We need to go forward with a program we can articulate that is also an abortion-reduction program,” he said. As an example, he described the conversation in which the provider asks what contraceptive a woman is using and whether she is using it correctly as a moral conversation that would result in fewer abortions.
Such a process, said Furedi, makes it more complex than it needs to be. “There is common ground that we need to prevent abortions,” she said. “We all agree. That discussion, however, doesn’t necessarily help us with the moral discussion that includes the circumstances of the pregnant woman.” How, she asked, can a person in Congress support contraception and not abortion? If they do, they should be called pro-contraception and not prochoice. “There is a difference,” she said.
“I don’t call myself pro-abortion,” said Carhart, “because I don’t think I am. I agree there is a difference. Prochoice leaves the choice up to the woman.”
Arguing for a broad definition of prochoice, Saletan said he would like to see an alternative proposal for counseling that gives the provider the freedom to counsel in a context-dependent manner. “At the same time,” he said, “counseling would be a standard provision.”
“You either agree a woman can make the choice or you don’t,” said Furedi. “Someone who places restrictions is not someone who is prochoice.”
Respect for the Fetus
Turning the discussion to how providers should care for the fetus, Shannon asked, “Do we owe the embryo respect?”
If one looks at conception to birth as a spectrum, said Saletan, it relieves the pressure to draw artificial lines. The basic idea is that at the point of conception, biology takes over to develop a human life. The more we learn about embryology and biology, he said, the more we are learning how to manipulate the process, which could lessen respect for the human subject.
“The embryo deserves respect,” Saletan said, “because it is an unfolding life. If we believe it is hard to clarify points at which an embryo is due respect, then we face the danger that the baby in the dumpster
will become a thing. We need to ensure that we don’t reach that extreme.”
Carhart countered with the example of a couple who, through in vitro fertilization (IVF), find themselves carrying three embryos but only want to carry one to term. Noting that science created the embryos, he asked if the termination of the two embryos could be justified. “We created that life,” he said, “God didn’t. Life does not have to be moral. We still have to let the woman make the determination about the life she is carrying. Otherwise there is no difference between an embryo and a cancerous growth, both of which were developed by God.” When
the baby can survive on its own, when the first breath is taken, he said, is an acceptable point to say life begins.
Agreeing with Saletan that an embryo should be given value as an unfolding human being, Furedi asked, however,
what it means to give value. “The value is less than that placed on the woman’s life,” she said, “less than the need for research to cure disease, less than an IVF-produced embryo. Giving value to an embryo does not mean I need to compromise my view on abortion and the use of embryos.”
“We don’t need to agree when life begins in order to give the embryo respect,” said Crane. “Giving respect to an embryo or fetus does not compromise one’s prochoice view.” “When we talk to women, we tell them that the fetus will have a place in their life forever,” said Carhart. “They make their decision knowing that we feel that way. We respect the fetus. Fetal tissue is cremated. We make arrangements for the fetus to be buried when the woman wishes.”
Respect for the embryo needs to be integrated into other issues, according to Saletan. “If value is equated with the embryo, the fear is the embryo will become an issue,” he said. “The use of embryos for medical research could dehumanize the fetus as the beginning of a person if it is not shown respect.”
Acknowledging that fetal pain is being talked about and that legislation is pending, Shannon asked if fetal pain is another antichoice strategy designed to put the prochoice movement on the defensive. How, she asked, should the movement respond to the discussion about fetal pain?
“I think the approach to fetal pain should be that we don’t know if the fetus feels pain and probably never will,”
Carhart said. “We should do everything so the fetus doesn’t experience pain.” By the 20th week, he said, the fetus responds to stimuli. “In his decision, the judge in the last partial-birth trial accepted that a fetus will respond to stimulus, but not that it feels pain,” he noted.
Acknowledging that women have always been concerned about fetal pain, Carhart said he uses sedation to euthanize the fetus after the 18th week. If legislation requires providers to change their procedures,
he warned, the result will be an increase in risk to the woman.
The NARAL position, said Crane, is that fetal pain is a topic of legitimate inquiry, not a political stance. “We feel it is a real unknown area of science,” she said. “Because we represent women who are
choosing abortion, we recognize women are interested. We are not enthusiastic, however, about the prospect for success when politicians get involved.”
“As a movement we need to respond to the inquiry with truthfulness,” said Furedi. “One thing we can say is that whatever the fetus feels or doesn’t feel is qualitatively different from what people feel as pain. When we talk about pain, we talk about a human experience that involves things outside neurological factors. One of the most insidious effects is projecting the fetus as a little person with the cognitive functions and experiences a human has. We have forgotten what it means to be human. Pain is a uniquely human experience.”
Referring to pending fetal pain legislation, Saletan said the requirement that a doctor must read a set text to the
woman is immoral. In general, he said, whenever legislation mandates that something must happen, morality becomes irrelevant. Instead, he said, what is working should be formalized, rather than introducing legislation. “My gut feeling is that it is better for politicians to say they support legislation that formalizes what is good,” he noted, “than to say legislation is not needed.”
Federal Ban on Abortion
The 2007 federal ban on a late-term method of abortion, Carhart said, has not made a difference in his practice. “The whole anti-choice movement is not about abortion,” he said, “but about denying a woman’s choice. The partial-birth abortion issue has become an easy thing to sell to the public because it is depicted as horrid. The legislation created an issue that sounds bad and made it illegal.” The gruesome pictures presented by former Sen. Bill Frist (RTN) do not accurately represent actual practice, he said. He added that that the original legislation, based on a presentation at a National Abortion Federation meeting by abortion provider Dr. Martin Haskell, would have made 90 percent of abortions performed between 12 and 16 weeks illegal.
The ban has forced doctors to develop new procedures, Carhart explained, which creates a learning curve for the skills required. He noted that he has seen some complications from the injections required to perform these procedures. “The devastating part,” he said, “is that the legislation gave the public the belief that Congress has the right to interfere in the patient-doctor relationship.”
Asked by Shannon what naral could have done differently in response to the legislation, Crane replied she wasn’t sure they could have done anything differently. “We had to oppose it because it opens the door for lawmakers to be further into the patient-doctor relationship,” she said. “My observation is that the anti-choice debate had stalled because the public has doubts about banning abortion. They were looking for a new way to approach the issue and late-term abortion allowed them to reinvigorate the conversation.”
“The issue of lawmakers inserting themselves into the patient-doctor relationship should have been opposed by the American Medical Association,” said Furedi. “It is a basic principle of medicine. This issue also has given the anti-choice movement confidence they can get results from the ‘yuck’ factor.”
An Ideal Prochoice Policy
In conclusion, Shannon asked the panelists to describe what they see as an ideal abortion policy for the country.
Stating that she would not include any health-care regulations, Furedi said the policy would be simply, “Abortion is a matter for a woman to decide and a topic for discussion with her doctor.” “The policy would be something like
Roe,” allowing women to make decisions about her pregnancy, said Crane, “but more comprehensive in the area of prevention and more robust in the publicly funded services that would be provided to women along the full spectrum, from conception to birth.”
“The policy would say abortion is a difficult part of the practice of medicine and the living of a woman’s life, and that the decisions involved are important,” said Carhart, adding that the policy language would strongly suggest women considering abortion talk to their family, clergy, and doctor before making their decision. Describing a fantasy policy that includes privately funded services, counseling and publicity to raise awareness, Saletan said women would be provided access to services to help them make reproductive decisions early in the process, with heavy emphasis on contraception.
“The policy would not only provide access,” he said, “but also guidance with input from the woman who has to make the decision. The funding would come from those who don’t want the government regulating abortion. Ideally, I would like to see a box I can check on my tax return that would make the money now spent on political fights instead be used to provide services.”