Correspondence
Abortion — 1995
N Engl J Med 1995; 333:875-877September 28, 1995
- Article
To the Editor:
As a physician with a busy general practice in obstetrics and gynecology (with a heavy emphasis on high-risk obstetrics and a special interest in infertility) and as a provider of abortion services for more than 20 years, I have a practice that exemplifies an integrated approach to the delivery of abortion services in the general field of obstetrics and gynecology. I heartily concur with Dr. Gottlieb's recommendation (Feb. 23 issue)1 that abortion services should be integrated with other aspects of reproductive health care.
Although abortion services represent less than 2 percent of the total volume of my practice (fewer than 20 procedures per month), I have been targeted by the local antiabortion activists (Operation Rescue Colorado and other, affiliated groups) as one of their three major targets in the metropolitan Denver area. (The other two are Planned Parenthood of the Rocky Mountains and a private abortion clinic.) My office, described in their literature as “the abortion mill,” is picketed three to five days per week, and patients (ranging from pregnant women at term to 72-year-old women with postmenopausal bleeding) are harassed indiscriminately with shouts such as “Don't kill your baby.” I have received at least seven serious death threats. Security costs for my practice exceed $2,500 per month. My home and that of my office manager have been picketed intermittently in attempts to incite our neighbors to violence against us. Since my principal hospital affiliation is a Catholic institution, pressure has been put on both the hospital and the Archdiocese of Denver to revoke my hospital privileges, and the hospital itself has been picketed repeatedly by demonstrators carrying signs saying such things as “Stop the abortionists who work here.”
Accordingly, I must disagree with Dr. Gottlieb's conclusion that mainstreaming abortion practices would reduce the potential for violence against providers.
1 ReferencesCharles H. Gartner, M.D.
1145 S. Federal Blvd., Denver, CO 802191
Gottlieb BR . Abortion -- 1995. N Engl J Med 1995;332:532-533
Full Text | Web of Science | Medline
To the Editor:
Bravo to Dr. Gottlieb for her Sounding Board article. The silence of organized medicine in the face of two decades of terrorist assaults on women, physicians who perform abortions, and personnel assisting in abortions has been nothing less than scandalous. Were such murderous rage and harassment unleashed against physicians who perform vasectomies, their patients, and their staffs, it is not far-fetched to believe that the American Medical Association and the American College of Surgeons would long since have voiced their outrage publicly. But in the face of the terrorist campaign against women and abortion providers by right-wing fanatics and religious bigots, organized medicine has responded with craven silence.
Barbara H. Roberts, M.D.
Cardiology Associates, Providence, RI 02904To the Editor:
Dr. Gottlieb correctly points out the failing of the medical and public health professions to integrate the practice of abortion into the mainstream of health care delivery. Her Sounding Board article makes a strong argument for the full integration of the practice of abortion into the mainstream of health care delivery, particularly with regard to training in obstetrics and gynecology. Yet throughout her article she fails to acknowledge the profound difficulties that abortion raises for many doctors and practitioners of obstetrics and gynecology in this country.
Abortion is unlike any other medical procedure in that it results in the direct termination of life. Dr. Gottlieb's statements that all programs “should guarantee their trainees adequate experience in first- and second-trimester abortions” and that “residents who wish to opt out of abortion training should be required to explain why in a way that satisfies stringent and explicit criteria” not only sound harsh, but lack appreciation of the moral issues that face so many of us with regard to the practice of this procedure. These “stringent and explicit criteria” could so easily be used to pressure residents to gain “adequate experience” in first- and second-trimester abortions. It would be profoundly immoral and destructive to the underlying principles of medical training to pressure trainees to perform a procedure that they may feel entails the taking of a human life.
I hope that in future discussions of the integration of abortion practice and training into the mainstream of health care delivery, participants will try to appreciate and respect the points of view not only of those who think that abortion is wrong, but also of those who are ambivalent and uncomfortable about performing an abortion themselves.
Timothy P. Flanigan, M.D.
Brown University, Providence, RI 02906To the Editor:
In reply to Dr. Gottlieb, I would like to offer a different point of view. As a third-year medical student assigned to obstetrics for my one-month rotation, I spent two weeks in the abortion clinic. Not having thought much about the ethics of abortion, I did my best to be a good student and do all I was told, unquestioningly adopting the pro-choice views of my instructors, who saw abortion as a political issue involving women's rights. Not until years later, when I came to believe firmly in the sanctity of human life, did I realize what I had done and had helped to do. It is with great sorrow and regret that I think back on the lives I helped to end and the frightened faces of the women whom I glibly reassured, without understanding the depth of the emotional and spiritual conflict that many were experiencing. What many probably needed was not to make their abortions faster, easier, or more “mainstream” and routine, but an opportunity to talk and think about how they felt about what they were going to do and what alternatives, social services, and support groups might be available to them. I agree with Dr. Gottlieb that “abortion must be included in undergraduate medical curricula,” but not as an assigned rotation in which students begin performing abortions before even thinking about whether they should be doing them. Students should be given the opportunity to discuss the ethics of abortion and exchange and explore their opinions about it. They should have the right and the opportunity to decide whether they really want to perform this procedure. The fact that there are medical reasons for performing abortions when the life of the mother is at stake is not a justification for performing the procedure when that is not the case. Taking a human life should be sufficient cause for both those having an abortion and those performing one to pause.
Joyce Show, M.D.
1809 Verdugo Blvd., Glendale, CA 91208To the Editor:
Gottlieb attempts to reduce the issue of abortion in 1995 to questions of the safety of providers, statistics about the outcomes of pregnancy, and the integration of the procedure into the mainstream of health care. No physician or person committed to healing can accept violence against or harassment of those providing abortion. However, the suggestion that increased access to abortion may decrease the rate of low birth weight and prematurity may be valid statistically, but many would ask just what considering such a cause and effect says about us as a people.
Throughout human history, and in every society, there have been physicians who have found abortion morally reprehensible. (This may have started with Hippocrates, whose oath before it was sanitized included the words “to give no destructive pessary.”) As long as this conviction persists, it is appropriate that abortion remain outside the mainstream of our healing process.
John J. Naveau, M.D.
Coldwater Medical, Coldwater, OH 45828-1697To the Editor:
Contrary to the belief of Dr. Gottlieb, the debate about abortion involves a single issue: religion. Abortion is anathema to the doctrines of Christianity, Judaism, and Islam. Attempts to resolve this debate in any secular forum nurtured by situation ethics rather than religious doctrine are doomed to failure. Residents wishing to opt out of abortion training need only say, “I do not wish to participate,” with nothing more required of them.
Harry H. White, M.D.
University of Missouri–Columbia, Columbia, MO 65212Author/Editor Response
Dr. Gottlieb replies:
To the Editor: The paucity of dialogue on abortion in the mainstream of medicine has allowed the issue to remain polarized and largely invisible. It is this climate that has restricted the opportunity for students to “discuss the ethics of abortion and exchange and explore their opinions.” The medical field must encourage discourse on abortion that is framed by science, information, and reason. As in other complex issues, such a framework can support the expression of diverse opinions and the exploration of the moral and ethical dimensions of the subject by trainees, providers, and patients.
I disagree with Dr. White's statements that “the debate about abortion involves a single issue: religion” and that “abortion is anathema to the doctrines of Christianity, Judaism, and Islam.” Each of these religions allows a range of interpretations of its doctrine as well as respect for the role of individual conscience in serious moral decisions and actions.1 In a secular democracy such as the United States, religious leaders and others who hold strong opinions based on their interpretations of religious doctrine may participate in the political process. However, the ultimate domain for the development of social policy and the execution of laws is secular and must be preserved as such.
Dr. Naveau states that I “reduce” the issue of abortion to the safety of providers and ignores the main point of the article — that abortion must be understood in the larger context of unintended pregnancy and women's health. Perhaps the following statement from the Institute of Medicine will convince him that it is only by addressing these larger issues that the need for abortion will be reduced; it is the only “win–win” solution in this debate: “The US Department of Health and Human Services . . . has urged that the proportion of all pregnancies that are unintended be reduced to 30% by the year 2000. Achieving this goal would mean, in absolute numbers, that there would be more than 200,000 fewer births each year that were unwanted at the time of conception, and about 800,000 fewer abortions annually . . . .” 2
I applaud and respect Dr. Gartner and others who have developed practices exemplifying the “integrated approach” to the delivery of abortion services. To reduce the potential for violence against providers, however, the most desirable integration includes, but must go beyond, the level of individual practice. Women's health must be broadly defined; primary care, family planning, and abortion services must be mutually integrated. These changes must take place at the systems level and will involve changes in administration, organization, and location and other structural changes. Over time, and in a medical climate that includes abortion as a mainstream issue, abortion will shed some of its outcast status. These are the conditions in which the potential for violence may be reduced.
2 ReferencesBarbara R. Gottlieb, M.D., M.P.H.
Brookside Community Health Center, Jamaica Plain, MA 02130
