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Interdisciplinary Views on Abortion: Essays from Philosophical, Sociological, Anthropological, Political, Health and Other Perspectives

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Interdisciplinary
Views on Abortion
Interdisciplinary
Views on Abortion
Essays from Philosophical, Sociological,
Anthropological, Political, Health
and Other Perspectives
Edited by
SUSAN A. MARTINELLI-FERNANDEZ,
LORI BAKER-SPERRY and
HEATHER MCILVAINE-NEWSAD
Foreword by SUE V. ROSSER
McFarland & Company, Inc., Publishers
Jefferson, North Carolina, and London
LIBRARY OF CONGRESS CATALOGUING-IN-PUBLICATION DATA
Interdisciplinary views on abortion : essays from philosophical,
sociological, anthropological, political, health and other
perspectives / edited by Susan A. Martinelli-Fernandez,
Lori Baker-Sperry and Heather McIlvaine-Newsad.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-7864-3494-7
softcover : 50# alkaline paper
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xxxxxxxxxx xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx
xxxxxxxxxxxx 2009
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British Library cataloguing data are available
©2009 Susan A. Martinelli-Fernandez, Lori Baker-Sperry and
Heather McIlvaine-Newsad. All rights reserved
No part of this book may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying
or recording, or by any information storage and retrieval system,
without permission in writing from the publisher.
Cover image: Xxxxxxxxxxxxxxxxxxxxxxxxxxxx
Manufactured in the United States of America
McFarland & Company, Inc., Publishers
Box 6¡¡, Je›erson, North Carolina 28640
www.mcfarlandpub.com
We dedicate this book to the women of Western Illinois Univer-
sity, who live with, around, through, and sometimes under the
reality of reproduction. We also dedicate this book to our stu-
dents who gave life and breadth to the initial course. Special
thanks goes to the women of Illinois and around the world who
loaned their voices to this volume. We also wish to acknowledge
the hard work of Carol Skiles for help in seeing this project to
fruition. Finally, our heartfelt gratitude to Polly F. Radosh, whose
steadfast loyalty and vision made our discrete intellectual com-
mitments and lives become collectively one, and individually
richer.
Table of Contents
Foreword: How This Book Exemplifies the Best of Women’s Studies
SUE V. ROSSER 1
Introduction
SUSAN A. MARTINELLI-FERNANDEZ and LORI BAKER-SPERRY 7
Abortion: A Sociological Perspective
POLLY F. RADOSH 19
Health and Medical Aspects of Abortion
KATHY FISCHER and SARAH R. GOFF 34
The Many Faces of U.S. Abortion Policy: How Government
Structure Results in Multiple Policies
AIMEE D. SHOUSE 55
Hidden in Plain View: An Overview of Abortion in Rural
Illinois and Around the Globe
HEATHER MCILVAINE-NEWSAD 77
Abortion, Polyphonic Narratives and Kantianism:
Quality of Life Matters
SUSAN A. MARTINELLI-FERNANDEZ 104
Staying Within an “Understanding Distance”: One Feminist’s
Scientific and Theological Reflections on Pregnancy
and Abortion
ALTHEA K. ALTON 122
Orphans, Abortions, and the Public Fetus in
The Cider House Rules
LORI BAKER-SPERRY 141
vii
Abortion and Mental Health
GAYLA ELLIOTT 171
Pedagogical Considerations for an Interdisciplinary
Course on Abortion
LORI BAKER-SPERRY 190
Concluding Remarks: The Uncertainty of Autonomy and
the Assuredness of Vagueness
HEATHER MCILVAINE-NEWSAD 198
About the Contributors 209
Index 213
TABLE OF CONTENTS
viii
Foreword
How This Book Exemplifies
the Best of Women’s Studies
SUE V. ROSSER
Women’s health served as a major impetus for the second wave of fem-
inism and the women’s movement in the 1960s, with access for women to
safe, legal abortion, contraception, and medical school heading the agenda.
After years of feminist activism and political coalition building, women’s
health now occupies a position in the mainstream of national medical research
and education agendas. Women make up about half of medical students.
Although few new methods of contraception have appeared in recent years
and a campaign for abstinence from intercourse has occupied the national
focus, contraception remains legal and widely used. In contrast, abortion has
become increasingly unavailable, with some doctors who perform abortions
having lost their lives to “pro-life” terrorists, and abortion is unlikely to be
the focus of research and publications that can be used in the classroom or
even discussed in educational institutions.
Women’s studies became the academic arm of the women’s movement,
with many of the first courses, readings, and programs initially developed
in the early 1970s. As one of the individuals involved in the first year of the
Women’s Studies Program at the University of Wisconsin in 1974–75, who
then went on to serve as a director of women’s studies for twenty-three years
at three very different types of institutions in different states, I recall very
well four of the criteria we applied in approving courses and selecting read-
ings for women’s studies. A central focus on women (and later gender) stood
as the primary criterion that could not be violated, since the major ration-
ale for women’s studies was bringing women into curriculum and research
from which they had previously been overlooked or excluded. The focus on
1
women led relatively easily to the other criteria such as development of
courses, research questions, and materials on new and controversial subjects
not traditionally part of academic research and curricula. For example, lit-
tle research and almost no courses on sexuality, including lesbianism, rape,
domestic violence, and menopause existed before women’s studies. Interdis-
ciplinary approaches became significant since the approaches and theories of
one discipline proved inadequate to understand these complex topics involv-
ing biology, psychology, sociology and culture. Because women’s experience
and activism had proved central in understanding these subjects and in mak-
ing a place for them in the curriculum, activism and experience were val-
ued along with theory, in women’s studies.
Interdisciplinary Views on Abortion exemplifies these four criteria:
Focus on women: With the topic of abortion, one might assume that
the focus would always be directly on women. As several authors, and par-
ticularly Aimee Shouse point out, much of the debate on abortion centers
on the fetus, the rights of the father, or the rights of the state to control the
process. This volume seeks to bring the focus back to women and abortion.
Controversial topic excluded from the curriculum: No one wants to
have an abortion. After the Civil War in the U.S., most states passed laws
overturning the traditional right of girls and women to abort during the first
trimester of pregnancy. These laws passed in the late 19th C. allowed licensed
physicians only to perform abortions when the pregnant woman’s life was
in danger, due to a medical condition. Until about 1950, most hospitals per-
formed legal abortions frequently and routinely for a number of medical
conditions, including severe psychiatric disorders. Beginning in the 1950s and
extending until Roe v. Wade made abortion legal in all states in the U.S. in
1973, medical-technological advances and improvements in obstetrics divided
the medical profession over abortions. Thinking of pregnancy as an added
burden that women with certain diseases and mental conditions could not
withstand became more difficult as improvements in technology and med-
icine decreased the situations in which the pregnant woman’s life was clearly
in danger. Abortion rates in the 1950s and 1960s decreased significantly over
the rates earlier in the 20th C. (Solinger, 1993). The legalization of abor-
tion in 1973 in Roe v Wade, reaffirmed by the Supreme Court decision on
Casey in 1992, made abortion, with some restrictions, likely to be legal for
the foreseeable future. As Polly Radosh documents, in recent years the num-
ber of abortions has decreased significantly under the Bush administrations
FOREWORD
2
by difficulties with access to abortion. Currently many obstetrician gynecol-
ogists are not trained to perform the procedure in medical schools.
As Susan A. Martinelli-Fernandez and Lori Baker-Sperry underline in
the Introduction, an impetus for the volume came from the fact that no
interdisciplinary text on abortion existed. The current politicization and
controversy surrounding abortion in the United States has led to a dearth of
research, courses, and even discussion about abortion in educational insti-
tutions. This dearth does not mean that women do not have abortions, it
simply means that they have less information before the procedure, have lit-
tle knowledge of the experience of other women who have had abortions in
similar or very different circumstances from theirs, and as Heather McIlvaine-
Newsad reveals, possess scant knowledge of how other cultures and coun-
tries view abortion. Interdisciplinary Views on Abortion helps to fill this dearth
by providing a tremendous resource of information and viewpoints on abor-
tion based on research and on women’s experiences in both the United States
and other countries.
Interdisciplinarity: As the controversy surrounding abortion demon-
strates, abortion is more than a medical procedure in the United States. As
it had in the first wave of feminism, a force motivating the wave of femi-
nism begun in the 1960s was women’s health concerns. Women sought the
right to control their own bodies through access to safe birth control, abor-
tion, and information about their physiology and anatomy, to define their
own experiences as a valid aspect of their health needs, and to question the
androcentric bias found in the hierarchy of the male-dominated health care
system and its approach to research and practice.
The interdisciplinary nature of most issues in women’s health and dis-
ease formed the raison d’être for health care professionals and researchers
from diverse specialties, professions, and disciplines to interact. They rec-
ognized that the traditional territory of obstetrics/gynecology failed to
include much of women’s health beyond the defined limits of reproductive
issues, and they expanded women’s health to include differences in frequency,
symptoms, and effects of diseases found in both sexes. The expanded
definition also requires linkages with researchers in liberal arts to understand
women’s health. Behavioral and social sciences, particularly psychology, soci-
ology, anthropology, and women’s studies, provided basic research theories
for domestic violence, eating disorders, and sexual and/or physical abuse,
now recognized as central to women’s health. These interdisciplinary
Foreword (ROSSER)
3
approaches need to be expanded further to include theology, philosophy,
political science, and cultural studies when considering abortion.
Fusion of activism with theory: Activist individuals, encouraged par-
tially by the women’s movement in the late 1960s, brought legal challenges,
including class action suits, against medical schools which had quotas on the
numbers of women, as well as racial and ethnic minority men, admitted.
Their legal challenge of the quota system stood as one of the first of many
critiques women presented to the medical profession. Women activists can
claim responsibility for initiating a demographic shift within the medical pro-
fession that increased the percentage of women medical school graduates
from about 7 percent in the mid–1960s to almost 50 percent today.
Much of the impetus for women’s health arose from community activists
in the women’s movement in the 1960s. In 1970 the U.S. Senate held hear-
ings on the contraceptive pill, organized in response to Barbara Seaman’s 1969
Book, The Doctor’s Case Against the Pill. In 1972, Belita Cowan created Her-
Self, the leading newspaper of feminist health, and Phyllis Chesler wrote
Women and Madness, critiquing sexism in the mental health system. These
individuals, along with Mary Howell, the first female dean at Harvard Med-
ical School and author of Why Would a Girl Go into Medicine? became found-
ing members of the National Women’s Health Network in 1975 in
Washington, D.C. (Pearson and Seaman, 1998). Consumer, community-
based organizations such as the National Women’s Health Network
(NWHN), the National Breast Cancer Coalition (NBCC), and the Boston
Women’s Health Book Collective (BWHBC) remain very active today.
Women’s health activists had proven key in the lead-up to Roe v Wade
in getting over-turned the century of criminalization of abortion that existed
from the late 19th Century when the American Medical Association (AMA)
successfully introduced statutes in all states by 1880 criminalizing abortion
unless performed by a “regular” doctor in a hospital. Some of these health
activists had set up underground networks that helped the estimated 1.2 mil-
lion women who sought “illegal” abortions each year before Roe v Wade
(Hunt and Joffe, 1994) to obtain safer abortions or aid women who need-
ing medical attention from botched abortions.
The editors and contributors to Interdisciplinary Perspective on Abortion
have taken an activist approach to this controversial topic of abortion, using
a variety of disciplinary lenses to re-focus the attention back on women and
abortion. The scholarly community in general, and women’s studies in par-
FOREWORD
4
ticular, owes them a debt of gratitude for creating this invaluable text that
exemplifies the best of women’s studies criteria.
References
Hunt, Jean, and Carole Joffe. (1994). “Problems and Prospects of Contemporary Abor-
tion Provision.” In Alice Dan (Ed). Reframing Women’s Health: Multidisciplinary
Research and Practice. Thousand Oaks, CA: Sage Publications.
Pearson, Cynthia, and Barbara Seaman. (1998). “When Were We Founded? And Just
What Were We Doing Back Then Anyway?” The Network News 3.
Solinger, Rickie. (1992). “Race and ‘Value”: Black and White Illegitimate Babies, in the
U.S.A., 1945–1965” Gender & History 4.
Foreword (ROSSER)
5
Introduction
SUSAN A. MARTINELLI-FERNANDEZ
and LORI BAKER-SPERRY
This book is the product of a semester-long course on abortion offered
in the women’s studies program at Western Illinois University. The genesis
of this course can be traced to a desire for a new, exciting course for stu-
dents and a forum for women’s studies faculty to share ideas, expertise, and
concerns in the areas of feminist research and feminist pedagogy. We deter-
mined that the “perfect” venue would be a semester long seminar on a topic
of particular interest to feminist and women’s studies faculty and students
alike. Various faculty members who have taught in the women’s studies pro-
gram were contacted to contribute a lecture and assume responsibility for a
particular class session. Additionally, a new faculty member was chosen to
coordinate the course readings and its activities. Because there was no inter-
disciplinary text available on the topic, each faculty member participating
in the seminar compiled information pertaining to her discipline on recent
research on abortion, with an eye to some theoretical issues addressed by var-
ious disciplines such as embodiment, autonomy, rights, and oppositional
ways of carving out intellectual and personal positions on the issue of the
permissibility of abortion. The information compiled became the basis for
this book.
Hence, this collection of essays is offered to provide an in-depth sum-
mary of some of the issues that arise when considering the topic of abortion
itself. In addition, some essays reflect original research and theoretical
approaches. Only the issue of abortion is covered in this text, although it is
situated within a wider understanding of the impact of reproduction on
women’s lives as well as on the lives of those who they hold dear. The objec-
tives of this book are threefold: (1) To trace issues surrounding abortion and
abortion practices in the United States through the lens of multiple disci-
7
plines; (2) to provide a readable and accessible summary of the recent research
on this topic and (3) to offer additional insight into the issue of abortion
through scholarship generated as a result of preparation for the course. The
interdisciplinary nature of this book parallels the interdisciplinary nature of
feminist and women’s studies, for it provides the reader with a variety of
disciplinary approaches, which together contribute to a broader and deeper
understanding of the complexity of the general issue of abortion. Also, many
of the articles include personal reflections on the challenges of striking and
maintaining a balance between personal and professional attitudes, beliefs
and commitments.
In this text, the authors represent different academic disciplines includ-
ing sociology, anthropology, philosophy, community health and health serv-
ices management, counseling, biology/theology and political science. The
first three essays, offering sociological, medical, and political perspectives set
forth theoretical issues as well as provide a general overview of the origin
and evolution of the abortion debate. In McIlvaine-Newsad’s anthropolog-
ical essay on women’s views on abortion and family planning in rural Illi-
nois serves as a bridge to the remaining essays, providing a turn from theory
to academic practices that utilize as well as reflect upon that theory.
Several of the essays included in this volume can be understood as pro-
viding the “facts” of abortion. These include Radosh’s “Abortion: A Socio-
logical Perspective,” Fischer and Goff’s “Health Aspects of Abortion,” and
Shouse’s “The Many Faces of U.S. Abortion Policy: How Government Struc-
ture Results in Multiple Policies.” Presenting the origins of the American
abortion debate, Polly Radosh discusses the sociological factors that affected
the late 20th century shift in the central issues of the debate. In addition,
this essay covers contemporary debates over abortion and discusses the down-
ward trend in the number of abortions performed each year. As a feminist
sociologist, Radosh provides a historical evaluation of the social acceptabil-
ity of abortion. Her argument traces the ways that the male medical model
(American Medical Association) co-opted the practice of abortion for a num-
ber of reasons, not the least being a right to control/dictate women’s bod-
ies, experiences, and autonomy. In a patriarchal society, this is implicitly
understood as an unquestioned natural right of many men.
Kathy Fischer and Sarah R. Goff’s essay, “Health Aspects of Abortion,”
provides an overview of the various abortion methods from a health and med-
ical perspective. Both medical and surgical abortion methods are addressed,
INTRODUCTION
8
including specific health risks for each method. Special emphasis is placed
on the recent increased availability of early medical abortion methods. A brief
description of emergency contraception is provided for the purpose of dis-
tinguishing it from medication abortion. Predictions are then made regard-
ing the implications of the increased availability of medical abortion and
emergency contraception for the patient and the provider.
Fischer and Goff also emphasize the importance of questioning current
physician-guided care and illustrate the need for an understanding of occur-
rence rates and clinical procedure. Partial-birth abortion is an example of a
“poster issue” with little statistical support, masking the reality of abortion
procedures in the construction of abortion as common practice of unlawful
death and not an issue of female control.
In “The Many Faces of U.S. Abortion Policy: How Government Struc-
ture Results in Multiple Policies,” Aimee D. Shouse evaluates the strategies
of pro-choice and pro-life interest groups as they try to influence the polit-
ical policy at the state and national levels. Using online legislative databases,
the author provides examples of state and national laws related to abortion
and discusses why pro-life and pro-choice groups might focus their efforts
at different levels and branches of government.
Shouse’s essay on the construction of the political debate today high-
lights the social and public nature of the abortion debate and the commu-
nal contestation of legal abortion. Understanding the impact of groups
involved, and the ways that they contribute to shaping and defining the
debate, is imperative. Furthermore, a description of the policies and prac-
tices that influence lawmakers is especially important in light of female access
to political process.
Moving from “facts” to testing theoretical assumptions, Heather McIl-
vaine-Newsad’s “Hidden in Plain View: An Overview of Abortion in Rural
Illinois and Around the Globe” draws upon first-hand anthropological
research to examine women’s views on abortion and family planning in rural
Illinois. Her inquiry begins with the premise that anthropologists believe that
both biological evolution and culture have shaped perspectives on and prac-
tices relating to reproductive issues. Her evaluation of the issue of experiences
of rural women illustrates the importance of evaluating race, class, and gen-
der in the abortion system. Her studies give rise to and address various ques-
tions: How do the female voices of McIlvaine-Newsad’s research indicate the
extent to which the issue of abortion is cultural, while patriarchy (literally
Introduction (MARTINELLI-FERNANDEZ and BAKER-SPERRY)
9
the “rule of the fathers”) is alive and well in all known cultural systems? Are
certain issues, even past the larger problem of inaccessibility, coloring rural
women’s choice to exercise a right? Whose voices can be determined to res-
onate with theirs or in their interests? And, simultaneously, whose voices can
be determined to influence their actions? McIlvaine-Newsad argues that to
understand the motivations of and reasons why women have or do not have
abortions based on a seeming dichotomy and an oppositional categorization
such as pro-life or pro-choice is unhelpful. Rather, the choice whether to
have an abortion is more meaningfully understood by reflecting on women
at various points in their lives and the concomitant desires, challenges and
goals of those times.
As a Kantian, feminist, and reconstructionist, Susan A. Martinelli-Fer-
nandez finds a middle ground between notions of autonomy, freedom, care,
other-regardingness, and respect for human as well as non-human nature.
By demonstrating how Kantian moral obligations arise out of particular rela-
tionships, she demonstrates how typical objections of abstraction, impartial-
ity and universality might be blocked using the example of terminal selection.
In so doing, she shifts the discussion from a rights-based discussion to one
where relational elements are considered.
Althea K. Alton’s essay on the biological and theological concerns related
to abortion is a clear break to the more traditional considerations of the abor-
tion question. Multiple theoretical elements and evaluation of key concepts
such as human, person, life, death, and authority are framed by the author’s
perspective as both a biologist and a theologian. Her discussion of the
mind/body dualism of Western thought mirrors the tension between her
own dual academic perspectives. A theology of embodiment may be seen as
a possible way to negotiate competing religious and scientific evaluations of
pregnancy and abortion within a feminist framework.
Focusing on the constructed nature of abortion in a social context, Lori
Baker-Sperry addresses the complexity of U.S. abortion debate today by
examining the degree to which the popular text turned film, The Cider House
Rules, reflects the current social ethos surrounding abortion and reproduc-
tion. Baker-Sperry uses this text in her college classroom, and argues that
The Cider House Rules is a litmus for the social opinion and normative beliefs
about abortion today. The author identifies themes in the text (pro-choice
as status quo, sin and penitence, pro-life perspective, the public fetus, how
the individual scenario sways opinion, and the business of abortion) that sup-
INTRODUCTION
10
port the argument that abortion is a complex and contentious topic. Baker-
Sperry argues that, even given multiple perspectives, abortion is always
brought to level of the personal story, and that story has the most power to
influence the individual belief or opinion on the subject. This is well-illus-
trated in the text The Cider House Rules.
Gayla Elliott’s essay presents a feminist case study focusing on an abor-
tion that was psychologically problematic for one woman, and how these
issues were helped or alleviated through counseling. Elliott argues that a
counselor must be open to evaluating the contributing factors in a given sit-
uation, some individual and some social, and that, while many women do
not experience psychological distress after abortion, the experience of abor-
tion is individual and must be treated as such. Elliot finds, in this case, that
the lack of power and control over life in general and reproductive health,
specifically, strongly influences one woman’s experience of abortion.
Through the lens of Elliot’s case study, we see that the notion of choice
is itself challenged, given the realities of physical and psychological limits.
How we understand choice is instrumental not only in understanding repro-
ductive and abortion issues; this understanding is key in to determining
whether women are, in fact, free and equal members of social, political, and
moral communities.
The essay entitled “Pedagogical Considerations for an Interdisciplinary
Course on Abortion” by Baker-Sperry describes the process of producing
and delivering a feminist course on abortion through the lens of many fields
including sociology, political science, philosophy, and community health.
With no appropriate composite reader available for the course, the individ-
uals presenting adopted essays and combined readings with materials col-
lected on the topic to present a thorough exploration to the students. This
book is a result of the work begun in that interdisciplinary course on abor-
tion.
In the concluding essay, McIlvaine-Newsad also reflects on the process
of creating an interdisciplinary text on abortion and considers the common
themes in these varied essays. Additionally, she addresses the need for a reader
of this scope and reiterates the arguments for the current study of abortion.
McIlvaine-Newsad closes by reviewing each essay through the unique lens
of an anthropologist’s perspective.
In the next section of the introduction, Martinelli-Fernandez and Baker-
Sperry reconstruct initial conversations with each other about the purpose
Introduction (MARTINELLI-FERNANDEZ and BAKER-SPERRY)
11
of this reader, and each particular essay One defining component of such
conversations is each editor’s disciplinary point of view; therefore each speaks
in her own voice, as philosopher and sociologist, as well as individual women
with a myriad of different experiences, personally and professionally.
A Philosopher’s Story (Susan A. Martinelli-Fernandez)
Many people believe that a woman’s political right to choose to have
an abortion is unquestionable. Yet, in reality, the “right” to an abortion is
restricted. This right to choose to have an abortion is grounded in the 14th
amendment, which involves a right to privacy. Looking at the history of the
legal permissibility of abortion in Roe v. Wade (1973) and Planned Parent-
hood of Central Missouri v. Danforth (1976), we see that a woman can fully
exercise her right to choose only in the first trimester of a pregnancy. In the
second trimester, the State has paternalistic supervision and in the third
trimester, the State can interfere as parenspatrial (of the fetus). This sug-
gests, from a political point of view, a woman does not have the full rights
of a citizen to freely determine the course of her life. From a moral point of
view, the woman is not seen as a full-fledged moral agent, who is responsi-
ble for her own decisions and leading her own life.
I start this introductory conversation with an emphasis on the differ-
ence between political and moral points of view because these perspectives
are too often conflated. Given this potential for conflation, readers need to
be aware of their own predisposition toward the topic of abortion and repro-
ductive issues. Further, while some of the essays might be read as making
specific normative recommendations, the purpose of each essay is to con-
tribute to a scholarly discussion about the immense complexity of trying to
discuss this topic. The topic of abortion is not tidy; it is messy. Yet, in their
very messiness, abortion and reproductive issues allow us to explore under-
lying attitudes about who we are and what we hold valuable as individual
women, as members of various relationships, as human beings, and as fel-
low citizens.
My own essay, “Abortion, Polyphonic Narratives and Kantianism: Qual-
ity of Life Matters,” attempts to isolate the moral problem embedded in per-
sonal decisions about the desirability of abortion from the political one.
Rights-focused discussions about the permissibility of abortion seem to con-
INTRODUCTION
12
tribute little to the moral deliberations of women deciding whether to pre-
serve or terminate a pregnancy. This is especially troublesome given that
modern advances in reproduction technology often result in pregnancies
involving multiple embryos.
Further, the idea of using abortion techniques to preserve a pregnancy
helps us appreciate the paucity of talking about rights (generally understood
as legal), when considering the morality and moral implications of abortion.
Two initial arguments are advanced. First: I suggest that quality of life is
more morally relevant than rights-based considerations, when looking at the
issue of abortion from an interested individual point of view. Second: I
demonstrate how quality of life may be subsumed under the broader con-
cept of autonomy, understood as a Kantian moral concept. Specifically, I
hope to show how the second formulation of the Categorical Imperative and
its demand for people to treat each other as ends-in-themselves presuppose
a “relational” autonomy that requires respect for individuals’ quality of life.
Third: By integrating the concept of a polyphonic narrative with a deeper
understanding of Kantian autonomy and respect for quality of life, I sug-
gest that a feminist Kantian perspective can be constructed. If my arguments
are successful, both Kantian and feminist theory will be strengthened.
A Sociologist’s Story (Lori Baker-Sperry)
I was professor of record for the interdisciplinary course on abortion
offered in the Women’s Studies program. As a junior faculty member at the
inception of this book, a sociologist, and a professor of women’s studies, what
is my addition to a clearer understanding of the issue of abortion in the U.S.?
There is the tendency for many to think that all recently trained young fem-
inists are third wave. I am not sure that is what I bring to the table, although
I am certainly concerned with problems of essentialism in feminist study,
generalizing about the intrinsic, essential “nature” of women as shared by all
women. Essential nature defines and determines the person, which, in the
case of a pregnant woman has strong bearing on individual autonomy. These
shared essential characteristics are static, unchanging, and a historical and
the assumption of sameness across women is problematic in general, and
specifically in terms of reproduction, pregnancy, and abortion. This perspec-
tive pervades the everyday construction of women, even in the face of clear
Introduction (MARTINELLI-FERNANDEZ and BAKER-SPERRY)
13
evidence that women may not demonstrate such essential qualities. Juxta-
posed to this, environmentally constructed “characteristics” and/or expecta-
tions created by social, political, and economic forces define and describe
the individual position in the social structure (Martinelli-Fernandez, 2000).
Although anti-essentialism does question long-standing views, and calls
for a re-thinking of traditional categories of women, I am always surprised
when a feminist older than myself (I was twenty-nine when the course ran)
tends to expect very revisionist politics or, sometimes, the opposite (a nod
to the “malaise of third wave feminists,” the idea that we enjoy the benefits
of first and second wave activism but do not carry the good fight ourselves).
In fact, I often feel that I have one foot squarely in both second wave fem-
inist ideology and the anti-essentialist politic of the third or “no “ wave fem-
inist movement, a position reflective of my training and personal experience.
My colleague and co-editor, Susan A. Martinelli-Fernandez (of “A
Philosopher’s Story”), has been teacher, mentor, and friend. Susan A. Mar-
tinelli-Fernandez and Polly F. Radosh, who initiated the abortion project,
speak of their feminism as a journey, as developing with the years of teach-
ing and scholarship. The co-editors and the contributors have formed rela-
tionships during the development of this book, as well. These relationships
have provided opportunities to learn and to teach, to negotiate opinions and
personal beliefs, and to explore the reflexive nature of feminist study and the
individual experience. We hope similar experiences occur for readers. This
process has also provided another new place for feminist unity across disci-
plines at our particular institution that will, hopefully, only strengthen and
grow. At a more general level, the power of affiliation in a network of rela-
tionships is certainly one “feminist way.”
We are interconnected, all of us in Western society, by certain notions
about life, death, and morality. These are shifting notions, but ones born in
a particular cultural climate which encourages us to think about issues, such
as abortion, in particular ways. The connections between life and death are
not just opposites (as often characterized); rather, they represent a struggle
of regeneration and the continuity of a group. Life, death, and therefore
abortion, do not happen in a vacuum. The text, The Cider House Rules,
which I evaluate in my contributing essay, illustrates this point. Abortion is
not simply the clinical termination of pregnancy. Pro-life, pro-choice, anti-
choice, and the ever curious notion of an “anti-life” positionwhat do those
terms mean, outside of the context of the social world? We construct our
INTRODUCTION
14
terms, name our terms, place value and meaning to those words only in the
context of our lives with one another. Where the construct ends and begins
again is certainly a philosophical question, but also a sociological one, in
that histories change meaning. Historical time, the construction of our “social
stories,” and the lived experience of group (social) life must be examined to
realize abortion as an issue dependent upon time and place. It is also very
much a feminist question, in that defining the physiological pregnant body
in relation to a historically situated male (standard) body is past and current
practice, regardless of the particular form the construction of masculinity
takes in any given period. In this way, women’s and men’s choices and rights
and respective autonomy are historically defined, and socially created, as well
as manifested in ways infused with meaning and value. But this does not
occur in a powerless void and without the control of such. Sexuality, repro-
duction and the female body are cultural constructs based on power rela-
tions, not the natural, observable fact embodied by the essentialist view.
Therefore a discussion of abortion is never appropriate without context,
without an understanding of the value placed upon meaning through the
lens of power and privilege.
In the concluding section of “Abortion, Polyphonic Narratives and Kan-
tianism: Quality of Life Matters,” Martinelli-Fernandez stresses the impor-
tance of voice by asking “Whose voice?” I would reiterate by asking “Whose
construction of meaning is valued?” Who has the power to create meaning
in the abortion debate? Do the voices speak truth? Are the statements rep-
resentative of real women’s experiences? Of the experiences of all involved?
Or are we more comfortable with those voices that resonate with the status
quo, those voices who do not ask that we step outside of our (sometimes
pregnant) selves and evaluate the struggle— for that is what it is— that sur-
rounds the relationship between the born and the unborn, between the
bearer, the to-be-born, and those selves reflected at the heart of the discus-
sion (sometimes a part of the woman/pregnancy, at other times not).
In my essay, “Orphans, Abortions, and the Public Fetus in The Cider
House Rules,” I explore the complex nature of abortion as it occurs in a text
situated in the not so distant past where much has changed but much has
remained the same. A close reading of The Cider House Rules encourages par-
ticular questions, such as “Do we vilify abortion for some women, in some
placesboth historical and geographical and not others?” We speak for
the rights of the unborn, the fathers, the mothers, and for those who do not
Introduction (MARTINELLI-FERNANDEZ and BAKER-SPERRY)
15
wish to be a parent, as well, in our answers. We speak for and also as these
individuals. When we speak, we must also consider whose story we tell.
Much of the argument is not necessarily embodied in contemporary main-
stream or academic evaluations of autonomy, human agency, and personal
choice, but is, instead, enmeshed in the historical importance of control over
the construction of the argument. The issue no longer becomes an under-
standing of intentional oppression for oppression’s sake (to “keep women
down”), but as a much more complex system of casting women into dichoto-
mous roles. Therefore, we need to examine the historically situated, contex-
tualized version of the truth illuminated by a feminist analysis of The Cider
House Rules. Along these lines, my concern over abortion rights and the con-
trol of female sexuality is often difficult to address when evaluating at only
the individual or only the social levels. How much of our individual moti-
vation to preserve a pregnancy or seek abortion or information about abor-
tion is influenced, even unconsciously or as a normative unspoken, by issues
of rights and control? To evaluate abortion socially, medically, biologically,
and politically, is an extremely valuable activity, one of the main reasons
why an interdisciplinary perspective is important. Only then are we able to
explore the systematic relationship between abortion and women’s overall
social rights.
One might find that focusing away from the individual is certainly an
obvious reaction of a sociologist, seeing the social in the individual. Many
might argue it is essentialism in sociological research rearing its head. My
point in emphasizing the public nature of the abortion debate is not to start
disciplinary wars. It is important to understand abortion as a public and a
personal issue and as a topic in need of analysis and focus of study.
Martinelli-Fernandez outlines the importance of recognizing that
women negotiate multiple issues when considering abortion as a personal
option. She argues that this evaluation is not limited to a view formulated
in the more traditional rights-based language of philosophy, but also encom-
passes an affiliative notion of responsibility (in particular, levels of respon-
sibility and obligation) in which beneficence is defined as a form of obligation
based upon a particular relationship or set of relationships. This leads her
to an exploration of a polyphonic narrative to describe the multiple voices
that influence the abortion decision. Using the unusual and illuminating
example of multiple embryos to illustrate (test) the Kantian concept of auton-
omy, Martinelli-Fernandez demonstrates that an understanding based on a
INTRODUCTION
16
quality of life argument does not negate a more traditional notion of rights
and autonomy, but instead expands that formulation to include a feminist
understanding of an ethics of care and “relational autonomy.”
In fact, the “multiple voices” of the polyphonic narrative are at odds,
in some ways, with any hegemonic view of the normative constraints and
beliefs on the issue of abortion and here is a struggle. Normatively, abortion
is discussed in terms of right and wrong, pro and against, as Shouse illus-
trates in her analysis of political interest groups and the rhetoric of the abor-
tion debate. But, as Martinelli outlines, we often take many factors, including
the desire of others, into account in an abortion decision. We might begin
to sort the normative from the interactional influence of multiple voices as
we consider McIlvaine-Newsad’s essay on rural women in Illinois. Further-
more, there are currently connections to the understanding of individual
considerations and social forces (Radosh) and the subtlety (and sometimes
covert nature) of the normative expectation and its origins. Issues of access
and the politics of the procedure(s) (Fischer and Goff ) further inform the
reader as to the tension between the normative arguments surrounding abor-
tion and the real lived experience of pregnancy and/or the termination
thereof. These are certainly resonated in Alton’s piece focusing on the ten-
sions between the biological and the theological perspectives on abortion. A
follow-up to the more clinical and “objective” (an interesting term I use
tongue-in-cheek given the authors of the medical and biological pieces were
personally, a nurse and a theologian), is Elliott’s piece from a counseling per-
spective, where the focus is the psychological health and well-being of the
person, with biological arguments about when life begins and medical pro-
cedure firmly in the peripheral.
As Martinelli-Fernandez previously notes, each essay works holistically
to provide a picture of the issue of abortion in the U.S. as it has been dis-
cussed and is currently debated. The obvious importance of an interdisci-
plinary, theoretical, and substantive exploration of the topic of abortion
cannot be over-stressed.
Introduction (MARTINELLI-FERNANDEZ and BAKER-SPERRY)
17
Abortion
A Sociological Perspective
POLLY F. RADOSH
Abstract
For most of the second half of the 20th century Americans debated the
morality of abortion. After the 1973 legalization of abortion in the famous
Roe v. Wade U.S. Supreme Court decision, the opponents to legal abortion
became increasingly militant in their efforts to reduce the scope of this legal
option or to roll back the decision through a Constitutional amendment.
Militancy, demonstrations, blockades, bombings, and murder of abortion
providers characterized the 1980s and 1990s as the rights and legal restric-
tions were debated and resolved in the late 20th century. Prior to the Roe
v. Wade decision most of the advocacy for change had been on the side of
the proponents of legal abortion. The issue of abortion remains an impor-
tant political topic and one in which religious and moral values are hotly
debated. The late 20th century furor over this issue is unusual in the long
history of abortion, however, and may illustrate other more pertinent con-
cerns associated with women’s rights and emerging changes in gender expec-
tations than about the actual practice of abortion.
Almost all societies have practiced abortion at some time, and in the
U.S. abortions were relatively common and not punished or censured until
the mid 19th century. The 19th century movement to criminalize the pro-
cedure centered not on the morality of the practice, but on who should per-
form the service. As the American Medical Association formalized the
regulations for medical practice, services that had at one time been provided
by unlicensed female providers, such as obstetrics (midwifery) and abortion
were subsumed under the practice of medical doctors. The debate was not
over whether abortions should be performed, but over control of the prac-
tice and procedures. Through the first half of the 20th century doctors and
19
hospitals performed abortions if approved by a therapeutic board. The debate
did not begin to take on its present tenor until the 1960s, when it became
more difficult for women to obtain approval for a variety of reasons.
This essay covers the origins of the American abortion debate. The soci-
ological factors that affected the late 20th century shift in the central issues
of the debate are discussed. In addition, this essay covers contemporary
debates over abortion and discusses the downward trend in the number of
abortions performed each year.
Nineteenth Century Changes in Abortion Practices
Abortion in the United States was not regulated until the mid part of
the 19th century. Abortions were performed by midwives prior to organiza-
tion of the American Medical Association (AMA) in 1847 (Luker, 1984).
Midwives used herbs, such as ergot which is derived from a fungus on rye
grain, tansy, pennyroyal, savin derived from juniper berries, or aloe, to induce
abortion through contractions of the uterus (McGregor, 1998, p. 119; Day-
ton, 1991, p. 19). As in most cultures in the world, abortion was not consid-
ered to be a moral dilemma if the pregnant woman had not yet experienced
“quickening,” or become aware of movement of the fetus. Historically and
across cultures, the moment of quickening, which occurs in the fourth or
fifth month after conception, has been used as the method for determining
pregnancy. Women’s knowledge of their own bodies and acknowledgement
of their pregnancies has been the measurement used most consistently when
it was necessary to terminate a pregnancy. Common folklore in the early 19th
century stressed that quickening indicated that the pregnancy as “alive.” A
late menstrual period prior to quickening was often referred to as a “block-
age” which could be removed with herbs or manual manipulations by a mid-
wife (Trone 1997, p. 26). An 1812 Massachusetts court ruling affirmed that
common law upheld a woman’s right to abortion prior to quickening, as did
common practice throughout the United States (Tone, 1997, p. 26). Abor-
tion was a private matter and not subject to regulation, if performed shortly
after a missed menstrual period.
Abortion was of little concern to most people prior to the organization
and subsequent expansion of the AMA. The use of herbs to bring on a late
menstrual period was quiet, personal, and not subject to debate until the
INTERDISCIPLINARY VIEWS ON ABORTION
20
AMA began to try to prevent competitive practitioners from providing med-
ical advice in the latter half of the 19th century. The AMA was organized
primarily as a social club, with only about 100 members, in 1847. As late as
1900 they had only 8400 members (Weibe, 1967, p. 115). In 1859 the AMA
approved a resolution condemning the practice of abortion (Luker, 1984 p.
191). This action initiated a shift in the abortion debate. Only 10 states had
laws prohibiting abortion or limiting the herbs used as abortifacients prior
to the AMA resolution (Trone 1997, p. 138). These state laws reflected con-
cern that women would be harmed by the herbal remedies, rather than with
the moral question of abortion.
Professional medical practice in the United States emerged after the
AMA began to advocate for higher standards of practice. Physicians in the
1850s had little scientific information upon which to build the practice of
medicine. As the profession began to formalize one of the strategies employed
by the AMA for improving public perception of physicians was to claim
superior scientific knowledge. Physicians actually had little scientific knowl-
edge and were often guided by superstition, religious belief, or ancient tra-
dition. In fact, many physicians resisted new scientific theories or practices
that challenged traditional methods. When the well-known 19th century
physician, Charles Meigs, was presented with the theory of contagion, for
example, he was insulted and refused to use the sanitary procedures that had
been recommend by colleagues in European hospitals. He said:
I have in numerous instances, gone from the bedside of women dying with
childbed fever, whether sporadic, or to the most malignant degree epi-
demic, without making my patients sick.... I did not then, nor should I
now, fear to be the medium of transmission.... I did not merit to be
regarded as a private pestilence... [Meigs 1854, p. 103].
Meigs, like most physicians, advocated that education in medicine
should rely on the apprentice system of practice under the guidance of an
experienced practitioner. Until the discovery in 1860 of the bacillus that
causes anthrax, medical practice was based upon the intuition of the prac-
titioner and the folklore of treatment. Physicians had little evidence to dif-
ferentiate diseases from symptoms (Friedson 1970, p. 16). Educational
requirements were minimal. Almost anyone with an elementary education
could take a course of lectures, pass an exam, and become a doctor in the
mid 19th century. In 1900 many medical schools admitted students who
could not get into liberal arts colleges (Shryock 1966, p. 152).
Abortion (RADOSH)
21
After Louis Pasteur’s work on the anthrax virus, medical science and
treatment techniques improved profoundly and medicine began to abandon
folklore and rely on science as the foundation of practice. The issues of edu-
cation, standards of practice, and maintaining dominion over the field of
medicine dominated the foci of the AMA between 1880 and 1920. Not only
was it necessary to improve the practice of medicine, but the public had to
be convinced that doctors could do more for their patients than midwives,
lay healers, herbalists, and other practitioners who had provided medical
treatment that equaled or surpassed that provided by physicians at the time.
As a result, much of the rhetorical reference to physicians in the late 19th
century focused upon the superiority of their medical knowledge. By 1910
the AMA had increased its membership to 70,000, and to 60 percent of
physicians by 1920 (Weibe 1967, p. 115). The AMA was unified by goals that
stressed educational requirements for all members, scientific research, supe-
rior medical care, and limited entry into the field of medicine. The practice
of medicine was not as advanced as the rhetoric of the AMA and they fell
short of the goal of “superior” medical treatment in many respects. Mid-
wives, for example, lost fewer babies and had lower rates of maternal mor-
tality than physicians through most of the early part of the 20th century, in
spite of the fact that only European immigrant midwives were trained and
most Americans had learned their trade through apprenticeship (Abbott 1917,
p. 147; Hardin, 1925, p. 347; Folks 1902, p. 435). The AMA knew that
physicians’ care was equally as unskilled as lay practitioners, but the goal was
to convince the public that physicians were superior:
We can do very well without midwives, but physicians are indispensable.
The sensible thing to do is eliminate midwives and educate physicians until
they are capable of doing good obstetrics, and then make it financially pos-
sible for them to do it. Physicians cannot be properly trained in obstetrics,
however, until they can have the work midwives are doing, since 75 percent
of the clinical material otherwise available for teaching purposes now pro-
vides a livelihood for midwives [Ziegler, 1912, p. 1738].
It will not get us anywhere to say that midwives do just as good work as the
average doctor, which may be true. It should not be a question of the lesser
of two evils. Neither is fit. We want something better, we want well trained
doctors to attend women in confinement [Ziegler 1922, p. 412].
The process of defining the profession of medicine required not only
securing the venue of practice and eliminating competitors, but also con-
INTERDISCIPLINARY VIEWS ON ABORTION
22
vincing the public that physicians should make decisions regarding treat-
ment. Time-honored practices had to be abandoned and old-world knowl-
edge suppressed in favor of the new modern, scientific treatments offered by
physicians. Decisions about treatment should not be left to women, whose
lack of sophistication and ignorance of scientific knowledge could lead to
disaster. Charles Meigs’ description of women typified the condescension typ-
ical of the medical profession:
[I]t is easy to perceive that her [women’s] intellectual force is different from
that of her master and lord.... She reigns in the heart; her seat and throne
are by the hearthstone. The household altar is her place of worship and
service.... Home is her place, except when like the star of day, she deigns to
issue forth to the world upon all that are worthy to receive so rich a boon
and then she goes back to her home... [Meigs 1848, p. 40–42].
The AMA’s resolution in 1859 to condemn abortion was part of a much
larger effort to eliminate competitive practitioners, such as midwives, and
to support the claim that only physicians could make decisions that had at
one time been exclusively made by women. The goal was not to eliminate
the practice of abortion, but to eliminate competition posed by the practi-
tioners who provided abortions, and to secure this practice within the domain
of obstetrical expertise provided by physicians. Much of the anti-abortion
rhetoric of the late 19th and early 20th centuries focused upon the midwife
as the source of morbidity and mortality among women who used such serv-
ices. Death from abortion was targeted as a singular example of the inferi-
ority of midwifery services. Midwifery would be abolished, by this reasoning,
if the abortion services provided by midwives were illegal (Reagan 1997, p.
91). Elimination of midwifery would secure all obstetrical services, includ-
ing abortion, for physicians.
Twentieth Century Changes in Abortion Practices
Through most of the first half of the 20th century abortions were avail-
able and provision of abortion services was neither a public issue not a mat-
ter of medical controversy (Luker 1984, p. 49). As long as the medical
profession controlled the procedure, few people were concerned with the
issue of abortion. In 1939 about two million abortions were performed, with
about 1.7 million completed by physicians, 200,000 by midwives, and the
Abortion (RADOSH)
23
remaining 100,000 performed by unknown practitioners (Tolnai 1939, p.
425). A study completed by the New York Academy of Medicine found that
most abortions were requested by married women with children. The fact
that the most efficient birth control of the time had an effective rate of only
40 percent probably contributed to the fact that married mothers sought
abortion more often than any other group of women. In the 1930s, abortion
was illegal in most states, but fairly easily obtainable. If the mother’s life or
health were endangered by the pregnancy, physicians would perform an abor-
tion. Six states had no prohibitions to abortion (Tolnai 1939, p. 425).1Even
illegal abortions, often performed in “abortion parlors,” were rarely prose-
cuted. Penalties for death of a patient resulting from an illegal abortion
ranged from one to twenty years in prison, depending upon state law. Pros-
ecutions of physicians were very rare, however. Midwives were more likely
to be prosecuted and punished than physicians, but even in cases of death,
penalties were rare (Tolnai 1939, p. 425).
In the 1930s concern over the number of women who died from ille-
gal abortions was expressed in popular press publications and was denounced
by the medical profession, but it appears that little was actually done to cur-
tail illegal abortions. Legal abortion performed by a physician was also of
little concern to the public or the medical profession. It was estimated in
1939 that about 10,000 women had died each year of the decade as a result
of illegal abortions. The highest rates of fatality were among 35–39 year old
women who had been pregnant six or seven times. Nearly all deaths from
illegal abortion occurred among married women with three or more chil-
dren (Tolnai 1939, p. 425).
Through the first half of the 20th century, women obtained most abor-
tions from their physicians who determined whether it was necessary. Con-
ditions that are treatable today, such as chronic vomiting, cardiac problems,
diabetes, toxemia, or renal problems, would have presented more serious
medical concern and very likely were used as a rationale for medically nec-
essary abortions through the 1950s (Luker 1984, p. 37). By the mid part of
the century, however, treatment of these conditions was more advanced and
presented less reasonable justification for an abortion. In addition, another
trend in medical care that had emerged throughout the first half of the 20th
century had become the norm. In the early part of the century, most med-
ical care occurred in the home of the patient. Only five percent of all births
occurred in hospitals in 1900, for example. By 1930, close to one-third of
INTERDISCIPLINARY VIEWS ON ABORTION
24
births occurred in hospitals, but after World War II, most births had been
moved to hospitals. The same was true of many other medical procedures.
Abortions that were performed on the kitchen table of the woman’s home
in the early part of the century were gradually shifted to the physician’s office
or clinic by the 1930s, and then to hospitals in the 1950s (Luker 1984, p.
654–56). Oversight by hospitals opened up the discretionary decisions of
physicians that had previously been private. Review boards were established
in the 1950s to determine the medical necessity of abortion (Luker 1984, p.
58; Time 1962, p. 52).
By the early 1960s, the number of legal abortions had dropped precip-
itously and hospital review boards had become increasingly strict in appli-
cation of criteria that dictated medical necessity. Some hospitals used a quota
system, so that abortions would be denied if the quota for the month had
already been reached; others used a criteria system with a checklist of med-
ical reasons that had to be met prior to approval by the board; and others used
a market system that approved abortions for well-connected, affluent patients,
but denied poorer, applicants with fewer resources (Luker 1984, p. 57).
Other social factors also influenced a sharp decline in the number of
abortions that were approved as medically necessary. Catholic opinion, which
had voiced papal opposition to abortion as early as 1869, became more vocal.
Catholic hospitals did not perform abortions, but articulation of Catholic
opposition in the documents of the Second Vatican Council in 1965, state-
ments by Pope John XXIII and by Pope Paul VI brought the opposition of
the Catholic Church to public debate. An issue that had previously been
characterized as a medical decision was transformed into a moral debate in
the 1960s.
California was the first state to formalize in statute the particular mod-
ern standards to justify the procedure. Issues of physical and mental health
of the mother, deformity in the fetus, and termination of a pregnancy that
resulted from rape or incest were incorporated into California law in 1967
(Luker 1984, p. 88). Abortion on demand was not approved, but the Cali-
fornia law became the most liberal in the nation prior to the Roe v. Wade
U.S. Supreme Court Decision in 1973.
After Roe v. Wade, abortion as a moral dilemma was increasingly debated
in public and political discourse. Opposition to abortion has focused on
the life that is not lived as a result of the terminated pregnancy, while pro-
ponents of abortion rights advocate the woman’s absolute right to make
Abortion (RADOSH)
25
decisions about her own body. Feminist critics of abortion opponents have
pointed out that issues of control are still a central theme in the anti-abor-
tion campaigns. Notification laws, waiting periods, mandated supply of infor-
mation about consequences of the procedure, prohibition of discussion of
abortion in federally funded facilities, and other recently legislated restric-
tions on abortion rights have been aimed at shifting control of the circum-
stances surrounding abortion services to those who would discourage
abortion on moral grounds.
The Roe v. Wade decision opened a deep division between those who
support abortion rights and those who oppose. The 1980s and 1990s were
characterized by violent protests, bombings of abortion clinics, and murder
of practitioners who provided abortion services. Militancy was most pro-
nounced among those who opposed abortion on moral or religious grounds.
Women who sought abortions and doctors who performed them were char-
acterized as “killers.” Public opinion polls since Roe v. Wade have indicated
fairly consistent national attitudes about abortion, in spite of political posi-
tioning on the issue, however. In 1975, Gallup Polls indicated that 22 per-
cent of the American population believed that abortion should never be legal,
and 22 percent of Americans believed it should never be legal in 2005 (Pas-
tore and Maguire 2008). Similarly, support for abortion on demand, or under
some circumstances, has remained at about 78 percent of the American pop-
ulation for 30 years.
Political opposition to abortion has been a lightening rod for right wing
conservative and fundamentalist politicians since the mid 1970s. In spite of
prevailing national attitudes that indicate the majority of Americans believe
that abortion should be available, at least under certain circumstances, most
states have moved to restrict access through regulation of services. One of
the most important political moves to restrict abortion services was the Hyde
Amendment, passed in 1978, which cut off Medicaid funds for abortion
unless the mother’s life was in danger or in cases of rape or incest. Medic-
aid funded abortions had dropped by 99 percent within 19 months of pas-
sage of the bill (Jaffe, Lindheim, and Lee 1981, pp. 141147). In 1977, prior
to the Hyde Amendment, abortion rates for Medicaid recipients were three
times higher than for more affluent women. Critics of the Hyde Amendment
often point out that restriction of funding ultimately limits poor women’s
access to abortion services. Abortion has become, in other words, an option
for the affluent.
INTERDISCIPLINARY VIEWS ON ABORTION
26
In addition to the Hyde Amendment, a 1987 U.S. Department of Health
and Human Services ruling, usually called the “gag rule,” specified that fam-
ily planning clinics which receive federal funds may not offer abortion coun-
seling, or discuss abortion as an option in family planning in any way. While
numerous court rulings have affirmed state control over abortion services,
including parental consent laws, spousal notification, compulsory anti-abor-
tion lectures, waiting periods, specific restrictions on the places where abor-
tions are performed, and numerous additional limits, the gag rule stands out
as second to the Hyde Amendment in significance in restricting poor women’s
access to abortion. The rule was in effect until lifted by President Bill Clin-
ton in 1993. In 2001, President George W. Bush reinstated the gag rule as
one of his first official acts in office.
Abortion as an Issue of Power
Prior to the formation of the AMA, decisions related to pregnancy and
abortion were made primarily within the domain and control of women.
Midwives and the pregnant women they served decided the best course of
action within extant knowledge of pregnancy. Most people did not view
what would currently be called a first trimester abortion as a significant moral
issue. Common reference to menstrual abnormalities, dysfunctions, and
“blockages” or “obstructions” in historical sources suggests that folklore dic-
tated that women would be restored to balance if the obstruction was
removed by herbal remedy. Most people in the 19th century believed that
women were especially susceptible to uterine abnormalities that needed treat-
ment. A woman’s awareness of quickening indicated a real pregnancy. Some
have estimated that between 20–35 percent of 19th century pregnancies were
terminated as a means of restoring “menstrual regularity” (Luker 1984, p.
18–21). About 20 percent of pregnancies were aborted as late as in the 1930s
(Tolnai 1939, p. 425).
With the previously discussed professionalization of medicine, control
of abortion services shifted to the predominantly male medical profession,
but was largely unregulated until the second half of the 20th century. While
shifts in the place of medical treatment from home to office to hospital were
influential in tightening control over abortion decisions, there were other per-
tinent cultural issues that were also influential. The fact that restriction in
Abortion (RADOSH)
27
abortion availability coincides with the modern women’s movement, or the
second wave of feminism, is significant. Hospital boards in the 1950s
approved abortion in most cases. In the 1960s the approval boards became
more restrictive, prohibitive, and authoritative at the same time that women
began to advocate for other reproductive rights. The 1965 Supreme Court
ruling in Griswold v. Connecticut, for example, specified that state law pro-
hibiting use of contraception violated constitutionally guaranteed rights to
privacy.2Availability of birth control would, presumably, make abortion less
necessary, but hospital boards were increasingly reluctant in the 1960s to
give permission for abortion even in cases of fetal abnormality (Time, 1962a).
Issues of morality had been raised by the Catholic Church, and critique of
family organization and reproduction rights were a source of social and polit-
ical debate as the public became more aware of the issues raised by women’s
rights groups.
As private decisions about reproduction were publicly debated and
decided in courts, issues of morality in reproduction were also debated. Pre-
viously private decisions now became a matter of national concern. Moral
questions about family planning were called into question by the sexual rev-
olution, increased divorce rates, higher rates of single parenthood, challenges
to traditional family structures, and ultimately by religious teachings about
family. Those with traditional views of family and religion were often most
vehemently opposed to increasing reproductive choices, which many believed
to be the source of higher rates of divorce and pre-marital pregnancy.
As women advocated for more rights, advocacy for restriction of abor-
tion services became more apparent among those who held tightly to tradi-
tional roles for women. The nearly all male medical profession, state
legislatures, Congress, law professions, and clergy were undoubtedly threat-
ened by women’s increased advocacy for control over their own reproduc-
tive rights. Just as the medical profession of the 19th century wrestled control
over childbirth and abortion from midwives, medical professionals and law-
makers in the 1960s fought to maintain decisions about abortion services
within the domain of their professions. In both cases women lacked influence
in the decision making process. Nineteenth century women lacked the right
to vote and they were excluded from the AMA. Twentieth century women
had almost no representation in the medical, legal, or legislative professions,
nor among the clergy, as decisions about reproductive rights were debated
in these venues.
INTERDISCIPLINARY VIEWS ON ABORTION
28
Additionally, as women in the 1960s and 1970s advocated for opportu-
nities to participate in many social and cultural activities that had previously
been closed to them, resistance to changing social patterns was persistent.
The effects of efforts to improve women’s opportunities to participate in
education, occupations, professions, and to achieve equal social status with
men is well known as a cultural trend in the late 20th century. The back-
lash against women is not so well documented, however. Restriction of abor-
tion services falls within the realm of this backlash and has become a struggle
over power in reproductive decisions. Those who advocate most vehemently
against abortion rights commonly hold highly traditional views about
women’s roles in society and in the family. Not surprisingly, those who advo-
cate for abortion rights usually hold very liberal views about women’s rights.
In the first year after the 1973 Roe v. Wade decision, there were over 50
bills introduced to restrict the right to abortion, and the onslaught of oppo-
sition to this legal option has not faltered since 1973 (Faludi 1991, p. 412).
Anti-abortion proponents since Roe v. Wade have characterized those who
support abortion options as anti-family, radical feminist, baby killers, who
are destined to destroy the nation (Faludi 1991, p. 411–413). The fact that
abortions have been a normative solution to unplanned pregnancy for thou-
sands of years is irrelevant in the present rhetorical assault on women’s rights.
To advocate for abortion choice was to advocate against the family in the
post Roe v. Wade political polarization. Most leaders of the anti-abortion
political movement have been men, including leaders of Operation Rescue,
Focus on the Family, Americans United for Life, the Christian Coalition,
Life Dynamics, Inc., the Pro-Life Action League, and the National Right to
Life. In the words of Operation Rescue leader, Randy Terry:
Radical feminism gave birth to child killing ... radical feminism, of course,
has vowed to destroy the traditional family unit, hates motherhood, hates,
children for the most part, and promotes lesbian activity. [Margaret Sanger]
was a whore, an adultress, and slept all over the place, all over the world,
with all kinds of people [quoted in Faludi 1991, p. 408].
Leaders of these organizations are often men who believe deeply that
family life requires a divinely ordained system of patriarchy. Women who
support these organizations also believe that women are biblically required
to serve men in marriage and that abortion not only interrupts a divinely
ordained order, but also challenges the God-man-woman hierarchy. Cer-
tainly there are those who oppose abortion rights exclusively on the basis of
Abortion (RADOSH)
29
moral values about the origins or meaning of life, but those who have been
most vocal, militant, and widely publicized have espoused feminist critique
of patriarchy as immoral and abortion rights as the symbol of feminism.
Issues of power still dominate the abortion debate; only the domain of
power has shifted. Those who advocate for abortion rights still maintain that
the power to choose whether to parent should rest with women who must
bear the physical responsibility of reproduction. Those who advocate against
abortion rights are no longer only those who want to control the procedure,
but now also include those who want to control women’s lives and options.
The 19th and early 20th century debates concerned who should provide
services; the current debate focuses upon who should control women’s lives.
Those who advocate against abortion rights often believe in traditional
restrictions on women’s opportunities. To affirm abortion is, symbolically,
to affirm social, economic, political, and reproductive choice, which is usu-
ally incompatible with the values and beliefs of those who oppose abortion
rights. While moral issues related to life, conception, and divine interven-
tion in the initiation of life are at the forefront of anti-abortion arguments,
the moral issues in the second tier of the debate generally return to social,
political, and reproductive freedoms for women, which threaten traditional
views.
Current Trends in Abortion
Since Roe v. Wade, the courts have continued to affirm women’s rights
to abortion, but also to allow states to limit or restrict access on a variety of
grounds, as previously discussed. The current climate, under appointments
made by President George W. Bush, is for increased restrictions. His rein-
statement of the gag rule on his first day in office, January 22, 2001, fore-
shadowed subsequent appointments to federal office that worked to reduce
access to abortion and contraceptive services for American women. Presi-
dent Bush’s removal of contraceptive coverage for federal employees from his
first federal budget (2001), and subsequent appointment of “abstinence only”
proponents to key public health offices and international agencies, such as
the Office of Health and Human Services, the United Nation’s Children’s
Summit, and the State Department Bureau of Population, indicate ongoing
administrative efforts to roll back access to abortion and contraceptive serv-
INTERDISCIPLINARY VIEWS ON ABORTION
30
ices. Among the most important actions of the Bush administration has been
support of legislative initiatives to redefine the meaning of “fetus,” such as
those in the Children’s Health Insurance Program (CHIP), the Unborn Vic-
tims of Violence Act (2001) and the Child Custody Protection Act (2002),
which assign particular rights to “unborn” children (Planned Parenthood,
2003). Proponents of abortion rights believe that separate administrative
and legislative actions that assign rights to the unborn will eventually be
used in totem as a mechanism for overturning Roe v. Wade.
The rate of abortions in the United States has been declining for sev-
eral years. In 2005 it reached its lowest level since 1974, at 19.4 abortions
for every 1000 women aged 15–44, or about 1.2 million abortions (Gutten-
macher Institute, 2008; New York Times, 2008). Over 95 percent of abor-
tions are performed in the first trimester of the pregnancy. The majority of
women who have abortions are white (70 percent), not married (60 percent),
and about half already have children (Planned Parenthood 2003). Reasons
for the decline are mixed. Some believe that increased effectiveness and bet-
ter access to contraceptives may decrease the need for abortions. As some
states have expanded family planning services under Medicaid, abortions
have declined, which suggests that when women have better access to birth
control they are less likely to need abortion as an alternative family planning
method (Reuters 2003). Proponents of restricted access to abortion believe
that increased obstacles to attaining abortion have discouraged women from
using this option, which encourages further efforts to restrict abortion alter-
natives.
Conclusion
Abortion rights issues have taken on their current format only since the
1973 legalization of abortion in the Roe v. Wade decision. Ironically, abor-
tion is probably less accessible today than it was two hundred years ago,
when removal of “blockages” were routinely accomplished by herbal reme-
dies. Modern birth control makes the need for abortion less urgent as a fam-
ily planning tool, but even modern birth control is not always available,
reliable, or accessible. Unplanned pregnancies and the responsibility of
women to endure the physical consequences are still very real. Issues of power
and control have remained central to the abortion debate for 150 years.
Abortion (RADOSH)
31
While death from illegal abortion has been problematic for American
women for over 100 years, the majority of abortions performed in the United
States prior to the 1950s were legal. The availability of legal abortion became
increasingly restrictive between the late 1940s and Roe v. Wade in 1973. While
legalization in 1973 may have solved the issue of an absolute right, efforts
to control this right began immediately after the decision, and have contin-
ued since the 1973. Fundamental issues include not only the problem of
access to abortion, but also definitions of women as independent, autonomous
agents. Efforts to control abortion are frequently tied to attempts to limit
women’s rights to act independently in other areas of modern life. As is evi-
dent from much of the anti-abortion rhetoric, abortion is not only a matter
of reproductive choice, but also a symbolic point of departure from tradi-
tional gender roles.
Notes
1. Florida, Louisiana, Massachusetts, New Hampshire, Pennsylvania, New Jersey.
2. Griswold v. Connecticut 381U.S. 479 (1965).
References
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Dayton, C. H. (1991). Taking the Trade: Abortion and Gender Relations in an Eigh-
teenth-Century New England Village. William and Mary Quarterly, 3d Ser. 48 (1),
19–28, 40–49.
Faludi, S. (1991). Backlash: The Undeclared War Against American Women. New York:
Anchor.
Folks, R. (1902). Obstetrics in the tenements. Charities and the Commons, 9 (18), 429–438.
Friedson, E. (1970). Professional dominance: The Social Structure of Medical Care. New
York : Athert on .
Guttenmacher Institute (2008). Facts on Induced Abortion in the United States.
http://www.guttmacher.org/pubs/f b_induced_abortion.html ( June 18, 2008).
Hardin, E. R. (1925). The Midwife Problem. Southern Medical Journal, 18 (5), 347–350.
Luker, K. (1984). Abortion and the Politics of Motherhood. Berkeley: University of Cali-
fornia Press.
Jaffe, F. S., B. L. Lindheim, and P. R. Lee (1981). Abortion Politics: Private Morality and
Public Policy. New York: McGraw-Hill.
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New Brunswick, NJ: Rutgers University.
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Meigs, C. (1854). On the Nature, Signs and Treatment of Childbed Fever. Philadelphia:
Lea and Blanchard.
New York Times (2008, January 26). Editorial: Behind the Abortion Decline. http://www.
nytimes.com/2008/01/26/opinion/26sat2.html (June 23, 2008).
Pastore, A. L., and K. Maguire (2008). Sourcebook of Criminal Justice Statistics. Wash-
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edu/sourcebook/index.html ( June 23, 2008).
Planned Parenthood (2003) http://www.plannedparenthood.org/library/facts/030114
( June 9, 2003).
Reagan, L. J. (1997). When Abortion Was a Crime: Women, Medicine, and Law in the United
States 1867–1973. Berkeley: University of California Press.
Reuters (2003, January 15). “Abortion Rate Down but Abortion Pill More Popular,” Per-
spective on Sexual and Reproductive Health, 35, 6–15.
Shryock, R. H.(1966). Medicine in America, Historical Essays. Baltimore: Johns Hopkins.
Time (1962, July 13). Abortion and the Law. 80, 52–53.
Time (1962a, August 3). Abortion and the Law. 80, 30.
Tolnai, B. B. (1939). Abortions and the Law. Nation, 148 (April 15), 424–7.
Tone, A. (1997). Controlling Reproduction: An American History. Wilmington, DE: SR
Books.
Weibe, R. (1967). The Search for Order, 1877–1920. New York: Hill and Wang.
Zeigler, C. E. (1912). Elimination of the Midwife, Proceedings of the American Associ-
ation of the Study and Prevention of Infant Mortality. Journal of the American Med-
ical Association, 59 (9), 1738.
Ziegler, C. E. (1922). How Can We Solve the Midwifery Problem? American Journal of
Public Health, 12 (5), 405–413.
Abortion (RADOSH)
33
Health and Medical
Aspects of Abortion
KATHY FISCHER and SARAH R. GOFF
Abstract
This essay provides an overview of abortion from a health and medical per-
spective. First, a brief overview of fetal development is presented. Next,
both medical and surgical abortion methods are described, including specific
health risks for each method. Special emphasis is placed on the recent avail-
ability of early medical abortion methods. A brief description of emergency
contraception (EC) is also provided for the purpose of distinguishing it from
medical abortion. In addition, predictions are made regarding the impli-
cations of the increased availability of medical abortion and emergency con-
traception.
The 1973 Roe v. Wade Supreme Court decision reaffirmed a woman’s
right to privacy under the ninth and fourteenth amendments, and protected
a woman’s right to seek a safe and legal abortion in the United States (Pich-
ler & Golab, 2007). Not only did the legalization of abortion provide women
with the freedom to seek abortion services from trained physicians in safe
and sterile environments, but also it virtually ended the back alley botched
abortion horrors of the past. Since the 1973 ruling, however, pro-choice and
pro-life advocates have vehemently clashed on many issues regarding abor-
tion, including a woman’s right to control her body, the morality of abor-
tion in early and late stages of pregnancy, fetal rights, and controversial
legislation such as parental notification and consent laws, waiting periods,
and federal funding restrictions. As a result, the disputes over abortion and
the politics surrounding the debate are far from resolved (Kolander, Ballard,
& Chandler, 2008; Pichler & Golab, 2007).
Approximately one-half of pregnancies in the U.S. are unintended, and
34
over 40 percent of these pregnancies are terminated by abortion each year.
Of the women who obtained abortions in 2002, the majority were either
Black or Hispanic, younger than 25, and identified themselves as never-mar-
ried. Women living below the federal poverty level were more than 4 times
as likely to have an abortion as women above 300 percent of the poverty
level (Guttmacher Institute, 2006). Facing an unintended pregnancy can be
an overwhelming and even devastating event in a woman’s life regardless of
her race, age, marital status, religion, or financial circumstances. Not only
must a woman deal with the initial shock of acknowledging her pregnancy,
but also she must face the often-difficult decision of whether to become a
parent, choose adoption, or have an abortion. For some, the word “abor-
tion” can evoke fearful images of pre–Roe back-alley butchers, septic infec-
tions, and uncontrollable bleeding. It is essential that women who elect to
have an abortion be provided with accurate information regarding the var-
ious abortion procedures, possible complications, and aftercare instructions.
Accurate and unbiased information dispels myths and eases concerns regard-
ing the safety of abortion, as well as promoting an empoweringrather than
shamefulabortion experience.
This essay provides an overview of abortion from a health and medical
perspective. First, a brief overview of fetal development is presented. Next,
both medical and surgical abortion methods are described, including specific
health risks for each method. Special emphasis is placed on the recent avail-
ability of early medical abortion methods. A brief description of emergency
contraception (EC) is also provided for the purpose of distinguishing it from
medical abortion. In addition, predictions are made regarding the implica-
tions of the increased availability of medical abortion and emergency con-
traception.
Overview of Fetal Development
This brief overview of fetal development is provided strictly from a
health and medical perspective. Ethical and spiritual aspects of abortion will
be discussed elsewhere in this book.
The entire duration of a pregnancy, from implantation to birth, is 266
days or 38 weeks although up to 40 weeks gestation is common. The
gestational period is divided into three phases called trimesters, consisting
Health and Medical Aspects of Abortion (FISCHER and GOFF)
35
of approximately 3 months each (Alexander, LaRosa, Bader, & Garfield,
2007).
Once fertilization of the egg by the sperm occurs, it takes 3–5 days to
travel from the fallopian tube to the uterus. When the cluster of cells reaches
the uterus to implant itself, its size is smaller than the head of a pin. Once
implantation occurs, it becomes known as an embryo. The amniotic sac
soon develops and envelopes the embryo. Amniotic fluid provides protec-
tion from shock and bumps, and helps maintain homeostasis. The placenta
soon forms, supplying the embryo with nutrients and oxygen and ridding
it of waste products. During the first month, the embryo grows to about 17
ounce in weight. By the end of the 8th week, the embryo becomes known
as a fetus and weighs about 16ounce. By 12 weeks gestation, the sex of the
fetus can be determined, the heart beats, and the kidneys begin producing
urine. By 14 weeks gestation, bones have developed, the head and extremi-
ties are formed, and the major organ and nervous system are formed. The
fetus now weighs just over 1ounce (Alexander et al., 2007; Kolander et al.,
2008).
During the second trimester, fetal growth becomes much more rapid.
Beginning with the 4th month, the mother can feel fetal movements and heart
sounds can be monitored with external instruments. During the 5th month,
detailed formation of bodily structures (e.g., eyebrows and fingernails) occurs
and the fetus now weighs between .75 and 1.4 pounds. By the end of the
6th month, the fetus kicks and turns over, has wake and sleep cycles, and
has a developed sense of hearing. It is between 10 and 11.5 inches long and
weighs about 2.1pounds. If the fetus is born during the 6th month, survival
is possible if intensive neonatal care is provided (Alexander et al., 2007;
Kolander et al., 2008).
By the end of the 7th month, the fetus weighs between 2.5 and 3
pounds, and if it is born it is generally able to survive. Growth continues to
occur at a rapid pace. By the end of the 8th month, it weighs between 4 and
5.5 pounds. Bones become harder and the skin has a wrinkled appearance.
During the 9th month, the fetus gains about an ounce of weight per day.
By the end of the 9th month the baby weighs between 6 and 9 pounds and
is between 16 and 22 inches long. The skin has become filled out and smooth.
It is ready for survival outside the womb (Alexander et al., 2007; Kolander
et al., 2008).
INTERDISCIPLINARY VIEWS ON ABORTION
36
Surgical Abortion Methods
There are four surgical abortion methods that are available depending
on the length of pregnancy or size of the fetus; they include vacuum aspi-
ration, dilation and evacuation (D&E), intrauterine installation with saline,
and hysterotomy (Planned Parenthood, 2007a). A fifth method, dilation and
extraction, was an option, but was banned in a 2007 ruling by the U.S.
Supreme Court in all cases except to save the life of the mother (Barnes,
2007).
Vacuum Aspiration
Eighty-nine percent of all surgical abortions are performed using the
vacuum aspiration and dilation and evacuation methods to terminate preg-
nancies between 6 and 16 weeks gestation, with the vast majority of these
using the vacuum aspiration method (Centers for Disease Control and Pre-
vention [CDC], 2006; Knowles, 2002). This procedure is provided on an
outpatient basis, usually in a clinic or doctor’s office, and generally includes
the following: laboratory tests to confirm the pregnancy and to verify the
woman’s Rh factor type (positive or negative); counseling provided by a pro-
fessional staff member; and the reading and signing of an informed consent
form. The vacuum aspiration abortion is performed by administering a local
anesthetic, cleaning the inside of the vagina with an antiseptic solution,
dilating the woman’s cervix, and inserting a suction cannula through the
cervical opening (os) to aspirate the contents of the uterus. The procedure
is completed in 5–10 minutes and generally causes menstrual-like cramping
during and immediately following the abortion (Knowles, 2002).
After the abortion is complete, the patient is monitored at the facility
for 30–60 minutes, directed to rest that evening, and is provided with after-
care instructions. Most women can expect to experience variable bleeding,
clotting and cramping for 1–3 weeks after the procedure, and are advised to
refrain from heavy lifting and strenuous work and exercise for 5–7 days. A
post-abortion examination, including a low-sensitivity pregnancy test, is
recommended (but not required) 3 weeks following the procedure (Knowles,
2002). Although the complication rate for a vacuum aspiration abortion is
extremely low (less than 1percent), possible complications can include aller-
Health and Medical Aspects of Abortion (FISCHER and GOFF)
37
gic reactions to drugs, infection, retained tissue, hemorrhage, cervical tear-
ing, or uterine perforation (Planned Parenthood, 2007a; Guttmacher Insti-
tute, 2006).
Dilation and Evacuation
A dilation and evacuation (D&E) procedure is used to terminate a preg-
nancy between 14 and 24 weeks gestation (CDC, 2006; Knowles, 2002).
The D&E is almost identical to the vacuum aspiration abortion but requires
greater dilation of the cervix, as well as the use of a curette to scrape the
uterine wall and forceps to remove the products of conception (POC)
(Knowles, 2002). This procedure can be performed in one or two days, and
often requires the use of laminaria (also called osmotic dilators) to gradu-
ally dilate the cervix (Knowles, 2002). Laminaria consist of medically pre-
pared seaweed that is sterilized and compressed into the shape of small rods.
After being inserted into the cervix, the laminaria absorb moisture from the
woman’s body and gently expand to slowly dilate the cervical os. The woman
may feel moderate to heavy cramping during the insertion, as well as light
to moderate cramping prior to and during their removal. Depending on the
length of the pregnancy, some women may need two or more laminaria inser-
tions to adequately dilate the cervix (Lowdermilk, Perry, & Boback, 2000).
The D&E abortion can be performed using either a local anesthetic or con-
scious sedation, and takes approximately 10–20 minutes to complete the
procedure. Although the woman may be advised to rest for up to 2–3 days,
the other aftercare guidelines (including the post-abortion exam and possi-
ble complications) are identical to the vacuum aspiration abortion (Knowles,
2002).
Intrauterine Installation with Saline
The third surgical abortion procedure, intrauterine installation with
saline (also known as a labor induced method), is very rarely performed and
accounts for only 0.3 percent of abortions (CDC, 2006). This method is
used after the 16th week gestation and occurs in a hospital setting under local
or general anesthesia. The intrauterine installation with saline abortion is
performed by removing 200 mL of amniotic fluid and replacing an equal
amount of hypertonic solution (concentrated salt water) by injection. The
INTERDISCIPLINARY VIEWS ON ABORTION
38
injection takes approximately 15 minutes to administer, and the patient will
begin labor after several hours. The pregnancy tissue is normally delivered
within 24–72 hours, and pain management is required to counteract the dis-
comfort of contractions (Reeder, Martin, & Konicek-Griffen, 1997). Possi-
ble complications of the intrauterine installation with saline method include
infection, retained tissue, failed abortion, and hemorrhage (Lowdermilk et
al., 2000).
Hysterotomy
Like the intrauterine installation with saline method, the fourth surgi-
cal abortion method, hysterotomy, is rarely used (CDC, 2006). This proce-
dure is performed in the second or third trimester of pregnancy, usually after
other methods have failed. A hysterotomy is in effect the same as a cesarean
section, and can be performed either vaginally or abdominally (Reeder et
al., 1997). The procedure requires a general or spinal anesthesia, and includes
all the risks of major surgery (Reeder et al., 1997).
Dilation and Extraction (D&X, Intact D&E)
The dilation and extraction abortion method (also called D&X or intact
D&E) involves the dilation of the cervix and extraction of the intact fetus.
It is often referred to by pro-life groups as a “partial birth” abortion, a polit-
ical term not recognized by the medical community (Religious Tolerance,
2004). Specifically, the D&X procedure entails widely dilating the cervix and
delivering the fetus in the breech position, while simultaneously collapsing
the fetus’ skull by extracting the brain tissue to reduce the chance of injury
to the cervix (Grimes, 1998; Religious Tolerance, 2003a). When this proce-
dure is used, it is almost always during the latter part of the second trimester.
Based on the most recent statistics, the Guttmacher Institute estimated that
in the year 2000, 2,200 D&X procedures were performedconstituting
only 0.17 percent of all abortions performed in that year (Guttmacher Insti-
tute, 2007b).
In 1996, the American College of Obstetrics and Gynecology issued a
statement maintaining that in rare cases a D&X may be the most appropri-
ate procedure to save the life or preserve the health of a woman, and only
the doctor, in consultation with the patient, can make this decision (Reli-
Health and Medical Aspects of Abortion (FISCHER and GOFF)
39
gious Tolerance, 2003a). Likewise, in 1997, the American Medical Associa-
tion issued a position statement that it does not condone this procedure
except in rare cases where it would be safer than the induction method (e.g.,
severe hydrocephalus where the fetus’ head is extremely large, or the fetus is
dead or severely malformed) (“AMA recommends,” 1997). This begs the
question, “Why not let the medical community regulate itself?” However,
a realistic concern with self-regulation is the possibility that unscrupulous
physicians could perform unjustified D&X procedures, falsely claiming “pro-
tection of the health of the mother” as the criterion. In fact, there is evi-
dence that in the past, a physician in a hospital in New Jersey violated his
medical association’s regulations by performing numerous late second-
trimester and even third-trimester abortions for non-medical reasons (Reli-
gious Tolerance, 2004).
Emotional reactions to the D&X procedure, concerns regarding fetal
viability and fetal ability to perceive pain, and concerns regarding the abil-
ity of the medical profession to regulate itself (as discussed above), repeat-
edly generated controversial legislation attempting to place a ban on the
D&X procedure at the state and federal levels during the 1990s and early
21st century (Religious Tolerance, 2007a; Religious Tolerance, 2007b). In
fact, some witnesses gave disturbing testimony during some of these hear-
ingse.g., accounts of viable fetuses being aborted using the D&X method
(Gonzales v. Carhart et al., and Gonzales v. Planned Parenthood Federation
of America, Inc., et al., 550 U.S. 05–380 and 05–1382, 2007). During this
time period, several versions of the bill known as the Partial Birth Abortion
Ban Act were vetoed by former President Bill Clinton and stricken down by
the U.S. Supreme Court, based on ambiguous language as well as the exclu-
sion of any provision to allow for the procedure in cases to save the life of
the woman. However, in October 2003, the House of Representatives and
the Senate passed a new version of the Partial Birth Abortion Ban Act, and
the legislation was signed into law by President G.W. Bush in November of
2003thus declaring the use of this method illegal (Religious Tolerance,
2003b).
In April 2007, in a 5–4 vote, the U.S. Supreme Court upheld the fed-
eral Partial Birth Abortion Ban Act (Gonzales v. Carhart et al., and Gonza-
les v. Planned Parenthood Federation of America, Inc., et al., 550 U.S.
05–380 and 05–1382, 2007; Guttmacher Institute, 2007b). The Court ruled
that the ban is constitutional, deeming that: (a) it is not vague; (b) it does
INTERDISCIPLINARY VIEWS ON ABORTION
40
not unduly restrict abortion access (since there are other available methods);
and (c) it does not need to have a health exemption since there is no con-
sensus among physicians about the necessity of the D&X procedure (Gon-
zales v. Carhart et al., and Gonzales v. Planned Parenthood Federation of
America, Inc., et al., 550 U.S. 05–380 and 05–1382, 2007; Religious Tol-
erance, 2007c). It is anticipated that the Supreme Court decision will stim-
ulate increased political efforts by groups on both sides of the abortion
issuee.g., advocacy, lobbying, and campaigns to support like-minded can-
didates for Congress and the Presidency (Vaida, 2007). This ruling also opens
the door for more state policy makers to revisit abortion procedure bans
(Krisberg, 2007). In other words, the political battle over the “partial birth
abortion” issue is not over.
Issues Related to Prevalence of Surgical Abortion
In the year 2003, 1.28 million surgical abortions were performed in the
U.S. (Finer & Henshaw, 2006b). While overall abortion rates continue to
decline, the abortion rates among low income and minority women are
significantly higher than among college educated women, white women and
those with modest incomes (Finer & Henshaw, 2006a; Boonstra, Gold,
Richards, & Finer, 2006). More than half of all abortions occur within the
first 8 weeks gestation, 88 percent occur within the first 12 weeks, and almost
99 percent occur within 20 weeks gestation (Guttmacher Institute, 2006).
Abortions are increasingly being performed in the early stages of pregnancy
for several reasons. First, blood and urine pregnancy tests have become more
accurate and can identify a pregnancy by 1or 2 weeks after conception,
respectively (National Women’s Health Information Center, 2003). In addi-
tion, many abortion providers (37 percent) have begun to offer abortion
procedures at 4 weeks gestation or earlier due to the availability and more
widespread use of the manual aspiration technique that uses a hand-held suc-
tion syringe instead of the conventional aspiration machine (Goldberg, 2003;
Guttmacher Institute, 2006). Furthermore, improvements in ultrasound
equipment allow for pregnancy detection as early as 4 week and 3 days ges-
tation. These technological advances not only provide women with more
options, but also allow providers to perform abortions with greater accuracy
and fewer complications (Goldberg, 2003).
Health and Medical Aspects of Abortion (FISCHER and GOFF)
41
Over 140,000 abortions (11 percent of all abortions) are performed dur-
ing the 2nd trimester of pregnancy each year (Boonstra et al., 2006). Women
who decide to seek abortions later in their pregnancy do so for several rea-
sons, including the following: (1) genetic defects are generally identified using
amniocentesis, a procedure that cannot be performed until the second
trimester of pregnancy (Planned Parenthood, 2000a). (2) Some women
particularly those in their teensmay experience denial or not realize they
are pregnant until their pregnancy progresses into the second trimester
(Boonstra et al., 2006). (3) Some women may have difficulty gathering money
quickly enough to pay for a first trimester abortion. To illustrate, the aver-
age cost of a first trimester abortion (at 10 weeks gestation) is approximately
$372 (Boonstra et al., 2006). Most clinics require clients to pay for their
abortion prior to receiving the procedure, accept only cash or credit card,
and are unable to offer any significant financial assistance (Boonstra et al.,
2006). (4) Other reasons that women may delay seeking abortion services
include issues related to parental notification or consent laws, and problems
locating and traveling to a provider (Boonstra et al., 2006).
Although 93 percent of surgical abortions are performed in small clin-
ics or doctors’ offices, the number of surgical abortion providers has declined
steadily in the past 30 years (Boonstra et al., 2006; Guttmacher Institute,
2006). As of 2000, 87 percent of U.S. counties lacked an abortion provider,
forcing many women— especially those in rural areasto travel distances
of 100 or more miles to seek services (Boonstra et al., 2006; Guttmacher Insti-
tute, 2006). This lack of access is particularly challenging for lower income
women who cannot afford to travel, must arrange for childcare, and/or might
need the utmost discretion (Boonstra et al., 2006).
Medical Abortion Methods
Medical abortion, which accounts for eight percent of all abortions,
involves the use of medications to terminate a pregnancy up to 49— 63 days
after the first day of a woman’s last menstrual period (CDC, 2006; Planned
Parenthood, 2006). There are currently two medical abortion methods used
in the U.S.: (1) mifepristone (known as RU–486 in Europe) and misopros-
tol, and (2) methotrexate and misoprostol (American College of Obstetrics
and Gynecology [ACOG,] 2001). The Food and Drug Administration (FDA)
INTERDISCIPLINARY VIEWS ON ABORTION
42
approved mifepristone and misoprostol in September 2000 (National Abor-
tion Federation, 2001). Prior to that time (from the years 19942000),
medical abortions had been increasingly performed using the off-label
method methotrexate and misoprostol, the only method of medical abor-
tion then available (ACOG, 2001; National Abortion Federation, 2001). Any
physician who provides medical abortions must have the capability of assess-
ing the gestational age of a pregnancy via an ultrasound or sonogram, diag-
nosing an ectopic pregnancy (a pregnancy that develops outside the uterus,
most commonly in the fallopian tube), and providing the patient with a sur-
gical intervention in the case of a failed abortion (ACOG, 2001).
Mifepristone and Misoprostol
A medical abortion using mifepristone and misoprostol generally
requires three separate visits to the clinic or doctor’s office. On the first visit,
the woman is required to do the following: provide a full medical history,
submit to laboratory tests (including a pregnancy test), have a physical exam
and ultrasound, discuss her decision with a clinical staff member or physi-
cian, and sign an informed consent form. The first medication, mifepristone
(an anti-progesterone drug that blocks the effect of progesterone on the uter-
ine lining), is taken orally at the clinic to begin the abortion process. Forty-
eight hours later, the woman returns to the clinic (or remains at home,
depending on the physician’s and/or the patient’s preference) to insert the
second medication, misoprostol (a prostaglandin hormone that causes uter-
ine contractions), vaginally. Once this drug is administered, the pregnancy
is usually terminated within 4 hours (ACOG, 2001; Planned Parenthood,
2001).
Side effects from the combined medications include moderate to heavy
abdominal pain and cramping, bleeding, clotting, and gastrointestinal dis-
tress (i.e., nausea, vomiting, and diarrhea) (National Abortion Federation,
2001). The third visit, which occurs two weeks following the date of the
first visit, includes a follow-up exam, ultrasound, and pregnancy test to
ensure the completion of the abortion (ACOG, 2001; Planned Parenthood,
2001).
Between 92 and 97 percent of women who take mifepristone and miso-
prostol will abort their pregnancies successfully; on the other hand, approx-
Health and Medical Aspects of Abortion (FISCHER and GOFF)
43
imately 1–4 percent will require a surgical abortion to complete the process
(Planned Parenthood, 2006). Complications associated with medical abor-
tion include retained tissue, allergic reactions, severe bleeding, uterine infec-
tion, and in rare cases, death (Planned Parenthood, 2007a). Another possible
complication is a ruptured ectopic pregnancy. Doctors should make efforts
to diagnose an ectopic pregnancy prior to administering medical abortion;
however, they can be difficult to diagnose (Planned Parenthood, 2007a;
“Reports posted on abortion pill,” 2002).
There were no life-threatening complications reported until August
2002. Since that time, one woman died after having suffered a ruptured
ectopic pregnancy after receiving a medical abortion, and six women died
after experiencing severe infections from the rare bacterium Clostridium sor-
dellii (Gardiner, 2006); however, one of those women did not receive
mifepristone during her abortion. While the FDA is still investigating the
nature of the infection-related deaths, it was reported that misoprostol was
administered vaginally, not orally (as it recommended by the FDA), which
may have played a role in the infections (Rovner, 2006). As with any med-
ical procedure, it is of utmost importance that medical professionals are dili-
gent in detecting and treating any possible complications.
Methotrexate and Misoprostol
The procedure for medical abortion using methotrexate and misopros-
tol is very similar to that of mifepristone and misoprostol; however, it is
slightly less effective, and women may experience more undesirable side
effects. Also, this method always requires a minimum of three appointments
to the clinic or doctor’s office (Planned Parenthood, 2001). The protocol for
the first visit is the same as for the mifepristone/misoprostol method, the
exception being that she receives methotrexate instead of mifepristone.
Methotrexate causes cellular damage to the chorionic villi (the precursos or
the placenta) and is administered through an injection. Three to seven days
later, the woman returns to the clinic to receive misoprostol vaginally
(ACOG, 2001). The abortion usually occurs within 24 hours after the miso-
prostol insertion but may take up to 48 hours in some cases. Approximately
50 percent of patients expel their pregnancies the same day the misoprostol
is administered, and an additional 35— 40 percent will complete their abor-
INTERDISCIPLINARY VIEWS ON ABORTION
44
tions within the week The entire process can take anywhere from 14 to 28
days. Two weeks following the abortion, the woman returns to the clinic for
a follow-up exam and pregnancy test (Planned Parenthood, 2001).
Approximately 90 percent of women who receive the methotrexate and
misoprostol abortion will abort their pregnancies (ACOG, 2001). If the abor-
tion does not occur or is incomplete, either additional doses of misoprostol
can be given or a surgical abortion will be performed (ACOG, 2001). Bleed-
ing generally lasts longer with this method, and the side effects may be more
severe if additional doses of misoprostol are required. Complications are rare,
but can include severe bleeding, uterine infection, low white blood count,
and hair loss (ACOG, 2001; Managing Contraception, 2000). There have
been no deaths associated with this method; however, because of the longer
process involved with methotrexate, mifepristone is usually the preferred
method for medical abortion.
Issues Related to Prevalence of Medical Abortion
It is estimated that in the year 2003, 55,048 women had medical abor-
tions (CDC, 2006). Many abortion clinics have reported a considerable
increase in their usage of medical abortion since its FDA approval in the
year 2000 (Boonstra et al., 2006; Goldberg, 2003). For example, from 2001
to 2004, Planned Parenthood clinics reported a 15 percent increase in mifepri-
stone use among women seeking early abortions (Boonstra et al., 2006).
Although most medical abortions are offered at facilities that provide surgi-
cal abortion, “... nearly one-fifth of mifepristone sales are to providers that
are not abortion clinics” (Boonstra et al., 2006, p. 18).
Comparison of Medical and Surgical Abortion
Although a medical abortion may be perceived as being the more “nat-
ural” or “easy” method, it is important for women who may be considering
this procedure to know that a medical abortion involves much more than
ingesting a couple of pills. The woman must be prepared to monitor her
bleeding, check for the passage of pregnancy tissue, report any unusual or
abnormal symptoms to her physician immediately, cope with possible side
Health and Medical Aspects of Abortion (FISCHER and GOFF)
45
effects from the medications, and attend each of her scheduled appointments
until her physician has verified that the pregnancy is terminated (Planned
Parenthood, 2001).
The choice to seek a medical versus surgical abortion is a very personal
decision and involves weighing the advantages and disadvantages of each
method. For example, a surgical abortion is an invasive, one-day procedure
with a 99 percent success rate (National Abortion Federation, n.d.). Clin-
ics offer a local anesthetic and even conscious sedation, but the procedure is
generally not available to those less than seven weeks into their pregnancy
(National Abortion Federation, n.d.). A lack of privacy is a concern for some
women, but the procedure is predictable and patients rarely require a fol-
low-up exam to address complications (ACOG, 2001; National Abortion
Federation, n.d.).
A woman who chooses medical abortion avoids the invasive procedure
as well as the side effects of sedation medications. The success rate of 95 per-
cent is slightly lower than a surgical abortion, and the procedure takes con-
siderably longer to complete (Managing Contraception, 2000). Medical
abortions are restricted to early pregnancies and require a follow-up exam
to ensure the completion of the abortion (National Abortion Federation,
n.d.). The procedure involves multiple appointments, but many women are
comforted by the potential for more privacy as they abort their pregnancies
at home.
The costs for the procedures are comparable, averaging $372 for a sur-
gical abortion and $490 for a medical abortion (Boonstra et al., 2006).
In summary, a comparison of medical abortion and surgical abortion
follows: Medical abortion: (1) usually does not involve an invasive proce-
dure or anesthesia; (2) can be used any time in early pregnancy; (3) requires
two or more visits; (4) requires days to weeks to complete; (5) requires patient
participation in a multi-step process; and, (6) has a success rate of about 95
percent. On the other hand, surgical abortion: (1) involves an invasive
procedure and may involve the use of sedation; (2) often, cannot be per-
formed until 7 weeks gestation; (3) usually requires only one visit; (4) is
completed in a predictable period of time; (5) requires patient participation
in a single-step process; and (6) has a success rate of 99 percent (ACOG,
2001).
INTERDISCIPLINARY VIEWS ON ABORTION
46
Impact of Medical Abortion in the U.S.
The Impact of Medical Abortion on
Overall Prevalence of Abortion
Some anti-abortion activists had predicted that the widespread avail-
ability of mifepristone would lead to an increase in the overall number of
abortions. Thus far this has not been the case (Boonstra et al., 2006). This
should come as no surprise if one considers the impact of mifepristone on
the abortion rates in France, Great Britain and Sweden. Following the intro-
duction of mifepristone in those three countries, the overall abortion rate
remained unchanged. However, it did bring about a change in the timing
of abortions; a larger percentage of women in each of those countries are
now having abortions at an earlier stage of gestation. One might speculate
that the same phenomenon will eventually occur in the U.S. (Boonstra et
al., 2006).
The Impact of Medical Abortion on
Overall Accessibility of Abortion Services
As previously mentioned, the provision of medical abortion has been
limited mostly to specialized clinics (e.g., Planned Parenthood). But among
those specialized clinics, the use of medical abortion has increased dramat-
ically. For mifepristone, drug sales in the first quarter of 2002 were up 39
percent as compared with the first quarter of 2001. Over time, the propor-
tion of abortions performed with mifepristone is expected to increase steadily,
if the history of its use in Europe is any indication. Some abortion rights
advocates had hoped that mifepristone would be used by large numbers of
physicians in private practice, who could thus provide abortions in previ-
ously unserved areas; however, thus far this has not occurred in overwhelm-
ing numbers (Boonstra et al., 2006). Speculated reasons for this include the
fact that physicians must meet certain requirements that may create barri-
ers (e.g., skill in diagnosing ectopic pregnancy, the purchase of ultrasound
equipment) (Boonstra 2002a).
Health and Medical Aspects of Abortion (FISCHER and GOFF)
47
Emergency Contraception
Although not an abortion method, emergency contraception (EC) is
discussed here for the purpose of delineating it from abortion, as well as to
provide understanding of the recent impact of EC on the abortion rate in
the United States. Emergency contraceptive pillsnicknamed “the morn-
ing after pill”—contain the same hormones used in oral contraceptives, but
in larger doses. If used within 5 days of unprotected intercourse, they
significantly reduce the risk of pregnancy (Johnsen, 2006).
Even though large doses of certain brands of oral contraceptives have
been prescribed as EC for over 30 years, their use was very limited until the
late 1990s because until then there was no medical protocol. This necessi-
tated prescription by a method called “off label” use and even though this
practice was not illegal, it posed certain logistic barriers for physicians and
pharmacists (Planned Parenthood, 2000b). But in 1998 the first product,
Preven (a combination of synthetic estrogen and progesterone), was FDA-
approved and marketed expressly for post-coital contraception. Subsequently
in 1999, Plan B was approved as the first progesterone-only emergency con-
traceptive. Plan B has the advantages of being slightly more effective and hav-
ing a significantly lower rate of side effects (Planned Parenthood, 2000b;
Johnsen, 2006). A new development occurred in August of 2006 when Plan
B was approved for over-the-counter (OTC) use for women over the age of
18 (National Women’s Health Information Center, 2006). In the year that
followed, sales of Plan B doubled— increasing from about $40 million a year
in 2006 to almost $80 million for 2007 (Stein, 2007).
EC is widely misunderstood by the American public. One widely held
myth is that EC is a form of medical abortion (which is not true since it is
taken early, before a pregnancy occurs). Depending on what time of the cycle
unprotected intercourse occurs, in most cases EC is thought to prevent preg-
nancy by inhibiting ovulation and, less often, by preventing fertilization
(Weiss & Golub, 2006). Recent studies demonstrate that progestin-only EC
(e.g., Plan B) works strictly by preventing ovulation or fertilization and has
no effect on implantation. However, combination-hormone EC (e.g., Pre-
ven) may, in some cases, work by altering the endometrium, thereby inhibit-
ing implantation (Planned Parenthood, 2003). In this case it does not prevent
conception— in which case some may question whether combination-hor-
mone EC is an abortifacient. The answer to this question depends on one’s
INTERDISCIPLINARY VIEWS ON ABORTION
48
definition of when pregnancy begins. The American College of Obstetrics
and Gynecology defines the beginning of pregnancy as implantation not
conception (Murphy & Allina, 2003). However, there are those who dis-
agree with this definition, believing that pregnancy begins with conception,
in which case they would not discount the notion that combination-hor-
mone EC can act as an abortifacient in some cases (Religious Tolerance,
2002). However, considering the fact that the predominant type of EC being
dispensed in the United States today is Plan B, this is a moot point in the
majority of cases.
The sooner after unprotected intercourse that a woman uses EC, the
greater is the likelihood that it will be effective. If progestin-only EC is used
within 72 hours of unprotected intercourse, it reduces the risk of pregnancy
by 89 percent. If used within 24 hours, it reduces the risk by 95 percent.
Combination-hormone EC has a slightly lower effectiveness rate (Weiss &
Golub, 2006).
EC is a very safe medication. The most common side effects— nausea
and vomitingare typically mild ( Johnsen, 2006). One commonly asked
question is whether EC can negatively affect an existing pregnancy (e.g., a
woman takes EC not realizing that she is already pregnant). For example,
could EC cause a miscarriage or cause birth defects? The answer is that EC
does not pose any increase in risk for an existing pregnancy (NOT-2-LATE,
2003). The cost of EC varies widely. Plan B usually costs between $10 and
$45, depending on the type of clinic or pharmacy where it is dispensed
( Johnsen, 2006).
In spite of the fact that Plan B is now over-the-counter for women age
18 or older, barriers to access still exist. Obviously, the most formidable bar-
rier for women under the age of 18 is the fact that they must obtain a pre-
scription. This can cause delays in obtaining the medication, which can
decrease the chances that it will be effective (Guttmacher Institute, 2007a).
But even for women age 18 and older, lack of availability of Plan B can be
a problem. Some individual stores have refused to keep EC in stock. How-
ever, in April 2007, Wal-Mart announced that nationwide, its pharmacies
would stock EC and dispense it without discrimination and without delay.
A number of other drugstores have made similar commitments (e.g., CVS,
Walgreens) But there are other drugstores where consistent accessibility is
not yet a reality (Planned Parenthood, 2007b).
Lack of education about this relatively new method of birth control is
Health and Medical Aspects of Abortion (FISCHER and GOFF)
49
another major barrier. Many women and men still do not even know about
EC; much more needs to be done to increase public awareness (Guttmacher
Institute, 2007a). According to one recent study, doctors are overwhelmingly
failing to utilize opportunities to educate their patients about emergency
contraception. Even though it is now OTC, health care providers still need
to educate their patients about it (National Women’s Health Information
Center, 2007). Cost is another potential barrier— especially for low income
women. Many insurance companies do not cover the cost of OTC drugs,
and only a few states cover EC for women on Medicaid without requiring
a prior visit to a doctor or clinicwhich can cause delays in obtaining the
method (Guttmacher Institute, 2007a).
But in spite of barriers, the impact of emergency contraception usage
on the abortion rate is already being realized. According to estimates by the
Guttmacher Institute, in the year 2,000 alone, EC prevented as many as
51,000 abortions (Wind, 2002). It is estimated that the future potential for
EC is even greater; it could potentially prevent 1.7 million pregnancies and
800,000 abortions every year (Boonstra, 2002b). Compared to medical and
surgical abortion, EC is substantially cheaper and safer, more convenient
and private, and considerably less stressful.
In summary, the advent of emergency contraception as a widely avail-
able means of post-coital contraception has had a significant impact on the
incidence of abortion in the past several years. And as the usage of EC con-
tinues to increase in the next few years (as is expected), an even greater
decline in the annual abortion rate is likely to occur. Emergency contracep-
tion is a relatively safe and extremely valuable addition to women’s options
for pregnancy prevention. More information about EC can be obtained by
accessing these websites: www.plannedparenthood.org, www.agi-usa.org, or
www.NOT-2-LATE.com.
Conclusion
The following conclusions can be drawn from the essay’s discussion: (1)
The annual abortion rate is decreasing due in part to increased use of emer-
gency contraception. (2) Increased awareness of, and availability of, emer-
gency contraception could theoretically prevent the need for the majority of
abortions. (3) The majority of second and third trimester abortions could
INTERDISCIPLINARY VIEWS ON ABORTION
50
be prevented by increasing awareness of (and access to) emergency contra-
ception and first-trimester abortion. (4) Medical abortion and surgical abor-
tion are relatively safe. Women’s preference of method depends on a variety
of factors, some of which are not medical in nature. (5) Although medical
abortion offers some advantages over surgical abortion, it is not likely to
resolve access issues for rural women or economically disadvantaged women.
(6) Experts predict the continued increase in the incidence of medical abor-
tion and use of emergency contraception. (7) The political debate over the
dilation and extraction (“partial birth”) abortion method, as well as late-
term abortions in general, is expected to continue.
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INTERDISCIPLINARY VIEWS ON ABORTION
54
The Many Faces of
U.S. Abortion Policy
How Government Structure Results
in Multiple Policies
AIMEE D. SHOUSE
Abstract
Although abortion policy in the United States is often considered as a sin-
gle policy area, the reality is that there is a wide range of actual policies
across the country that deal with abortion. In fact, a woman’s access to
abortion can be influenced greatly by the state in which she happens to
reside. The origin of this diversity in abortion policy falls back to two struc-
tures of American government: federalism and the separation of powers.
There simply is no single place in government where abortion policy is made;
instead there are multiple locations, including the three branches of the
national government as well as the fifty states. This essay discusses how these
two governmental structures have influenced abortion policy in the United
States.
In a recent graduate seminar on American politics, I overheard one of
my students ask her classmates whether they had ever noticed how “we talk
about abortion in almost every class?” Upon realizing that I had walked into
the room and overheard her, she added brightly, “There’s nothing wrong with
that, of course ... it really seems to relate to every topic we’ve considered!”
Although I don’t recall mentioning abortion during every class, I don’t dis-
pute that it’s possible. The student was right in at least one of her assertions:
the topic of abortion can be used to illustrate almost every topic typically
considered in a course on American government and politics. Abortion is
clearly both a personal and a political issue. When abortion is discussed in
55
the United States, it’s often considered in the context of public policy; we
consider what is permitted, what is prohibited, who gets to make that deci-
sion, and who influenced that decision. These questions are consistent with
the classic definition of politics as “who gets what, when, how” (Lasswell,
1936). It is not too strong to say that one cannot fully understand abortion
in the United States without understanding government policies regarding
abortion and the politics of creating abortion policies, including who makes
those policies and the political influences on the policy making process.
Thus, the discipline of political science provides a necessary contribution to
any interdisciplinary consideration of abortion.
Abortion policy in the United States relates to numerous aspects of
American politics. The topic could easily be used thematically for an entire
class on American government and politics, providing depth to the study of
the political behavior and attitudes of voters, parties, and interest groups;
the role of political institutions, such as Congress, President, and the Supreme
Court; and the structure of government, such as federalism and the separa-
tion of powers. And that’s only in the realm of American politics; abortion
certainly has relevance to the study of comparative politics and international
relations, as well. Comparatively, one can look at abortion policy as a man-
ifestation of different cultures and government structures. In regard to inter-
national relations, the issue of human rights, generally, and abortion,
specifically, has influenced foreign policy decisions. In the United States, for
instance, foreign aid appropriations have mandated that the funds not be
used for the funding of abortions.
This essay, however, focuses exclusively on abortion in the realm of
American politics. In the United States, abortion has become a political
behemoth; it has, more than any other issue, been used to distinguish the
two major political parties in the United States from one another, and it is
an essential element in defining the liberal and conservative ideologies within
the United States (Adams, 1997; Carmines & Woods, 2002). No candidate
for state or national office can run a campaign without addressing this issue
(Abramowitz, 1995), and the candidates’ stance on the issue immediately
demarcates many of their supporters from their opponents. It’s easy to see
the politics of abortion played out in political campaigns and partisan debates.
It’s easy to see the protestors and supporters of abortion policy square off over
its legality and morality. More subtle, however, is how the very structure of
American government has influenced abortion policy in this country.
INTERDISCIPLINARY VIEWS ON ABORTION
56
James Madison, often referred to as the father of the Constitution,
addressed the influence of government structure on political behavior in The
Federalist Papers, Numbers 10 and 51. Madison explains that the very struc-
ture of the American system of government will affect the decisions made
by government and the interaction of people with the government. This is
because the structure of government constrains and limits the types of inter-
actions that can exist with, and within, the institutions of government. In
regard to abortion, the federalist structure of government and the separa-
tion of powers at the national level have a tremendous influence on the pol-
itics of abortion and abortion policy in the United States. This essay will
address these two structures of American government, examining how both
federalism and the separation of powers have affected the policy making
process and the actual policies regarding abortion.
The Structure of American Government: Federalism
Politicians and political observers often refer to “abortion policy,” in
the singular. Yet, in the context of the American system of government, it
is imprecise to refer to a single abortion policy because there is no one abor-
tion policy for the entire country. Although this is not common practice, it
is actually more accurate to refer to abortion “policies,” in the plural, pri-
marily because there is no single location at which abortion policy is made.
The American system of government is complex, characterized by a vertical
division of power between the national and state governments, called fed-
eralism, and a horizontal division of the powers of government at the national
level, generally referred to as separation of power. It is important to under-
stand the intent and function of both of these structures because they have
contributed to a dynamic of policy making that has clearly shaped abortion
policy in the United States.
The United States government is federalist in nature, meaning that the
sovereign powers of government are divided between the national and the
state governments. In simple terms, the national government has some pow-
ers, the state governments have other powers, and there is an area of over-
lap between the two.1Thus, in certain policy areas, such as education, most
criminal law, and the regulation of certain professions, the states have the
autonomy to make policy, leading to quite a bit of policy variation across
The Many Faces of U.S. Abortion Policy (SHOUSE)
57
the country. Conversely, the national government has authority over policy
areas as outlined in the Constitution or that have been interpreted as falling
within the constitutional parameters of the national government.
Federalism emerged from the framing of our government for both prag-
matic and principled reasons. Pragmatically, any system of government
devised for the United States was necessarily going to have to consider the
role of the states, since the states were already in existence and had devel-
oped their own government institutions and traditions. In fact, several states
had been colonies for over two hundred years prior to the Constitutional
Convention of 1787 and it was clear to the framers that it was unfeasible,
politically, to dispense with the states. As for a principled justification of fed-
eralism, the division of government power between a national government and
various state governments prevented any part of government from having too
much power over the people, something about which the framers of the Con-
stitution were concerned. Further, state governments could represent regional
interests while the national government could govern over issues of relevance
to the country as a whole. This division of power between the national and
state governments can mean that there is a great deal of variation across the
states in a single policy area and that both the state and national levels of
government may contribute different policies to a single issue of concern.
This division of power between the national and state governments
gives those individuals and groups who want to influence the decisions of
government multiple points of access into the policy making process. While
the national and state levels of governments have their own governing author-
ity, there is certainly some overlap in their authority over certain policy areas.
Thus, individuals or groups can attempt to further their interests at the
national level, or within the fifty state governments, or both, depending on
where their chances for success are the greatest. For instance, if the politi-
cal environment of one state is not particularly hospitable to a particular
interest, such as advocates for abortion rights, proponents of that interest
can simply target another state. Similarly, if focusing on the policy process
of fifty different state governments is too arduous, setting one’s sights on the
national government may be a more reasonable approach to influencing gov-
ernment policy. In short, groups with an interest in abortion policy can often
target the part of government most open to their views.
While this essay will later consider the effect of federalism on abortion,
a brief example from another policy area, same sex marriage, illustrates the
INTERDISCIPLINARY VIEWS ON ABORTION
58
policy variation that can exist in a federalist system of government. Laws
regarding marriage are a state function. Marriage licenses are issued by the
state and each state can mandate the procedure for attaining a marriage license
within its boundaries. The question of whether or not two people of the same
sex can marry is thus decided by the states, and there is a lot of variation in
how the states have addressed the question. Policies range from the tolerant
to the restrictive. Specifically, Massachusetts legally permits gay marriage and
New York is currently considering it, four states permit civil unions between
two people of the same sex but stop short of permitting “marriage,” eight-
een states have passed laws defining marriage as between a woman and a man,
and another twenty six have solidified this restrictive policy even further by
including a heterosexual definition of marriage in their state constitutions.
The source of this variation is complex, encompassing the richness of the
political and social climates of all fifty states. However, the political and social
climate of an individual state can affect which political interest groups are
most successful in having their interests represented in public policy.
The national government also became involved in the issue of gay mar-
riage when Congress passed the Defense of Marriage Act in 1996. As con-
troversial as it was, this law clearly demonstrates the potency of federalism
to influence the content of public policy. In essence, the law simply clarifies
that when an entity of the national government such as Congress or a bureau-
cratic agency uses the term “marriage,” it is referring only to a union between
a man and a woman. One might conclude that this is rather little substance
for such a controversial law. The explanation lies in our federalist system of
government. Because the definition and regulation of marriage is constitu-
tionally a state function, the national government could define marriage only
for itself and its functions, not for the country as a whole. Thus, there is no
single policy on what constitutes marriage in the United States. This can be
said about numerous policy issues, including the mundane, such as speed
limits and voter registration requirements, and the controversial, such as
environmental regulation and abortion policy.
The Structure of American Government:
Separation of Powers
In addition to federalism, the American government is characterized by
a separation of powers at the national level. The term “separation of pow-
The Many Faces of U.S. Abortion Policy (SHOUSE)
59
ers” is almost cliché in the United States, most often paired with the phrase,
“checks and balances.” These two structures of the national government are
not synonymous; they refer to two related, but different, mechanisms for pre-
venting the national government from becoming too powerful.2Separation
of powers gives each branch of government its own sphere of influence, its
own powers and responsibilities; it simply breaks up the legislative, execu-
tive, and judicial functions of government into different branches of gov-
ernment, so that no part of government can exercise too much power on its
own. Checks and balances give each branch of government some authority
over the powers of the others, such as the presidential veto or the Congress’s
ability to override a veto. Thus, it is more accurate to say that the Congress,
President, and Supreme Court are “separated institutions sharing power,”
rather than three autonomous entities (Neustadt, 1990, p. 29).
With each part of the national government having a different function,
each branch has its own influence and powers over public policy. Although
this is an oversimplification of these powers, in short, Congress writes the
law, the President and executive branch execute the law, and the judiciary
interprets and applies the law when specific disputes over the law arise. In
more detail, by writing the law, Congress gets to decide what is included and
what is excluded in legislation. Although the ability to determine the lan-
guage of legislation is its most potent power, Congress also has the author-
ity to oversee the implementation of law and it has ultimate control over the
government’s budget. In its turn, the President can veto a bill passed by
Congress or can sign it into law, if the bill is passed during his or her admin-
istration. However, for laws that already exist when the President assumes
office, the President can influence the implementation of the law by appoint-
ing people to the executive branch who are sympathetic to the President’s
views of that law. Further, the President can give directives to the executive
branch, called executive orders, on how the executive branch will carry out
its functions, and he or she can bring up issues for the public’s and Con-
gress’s consideration.
Both the President and the Congress can be proactive when it comes
to public policy, in that they can take steps to initiate the policy process.
The Supreme Court and other federal courts, on the other hand, are reac-
tive, having to wait until a case is brought to them before they can act. How-
ever, once the court has a case to decide, its effect on policy can be significant.
The Supreme Court not only can interpret and apply laws to particular cases,
INTERDISCIPLINARY VIEWS ON ABORTION
60
it can actually overturn laws that it perceives as violating provisions of the
Constitution. This process, called judicial review, applies to laws that are
passed either by states or by the national government and to actions by the
executive branch. Although there are exceptions, court decisions generally
explain what the national and state governments can or cannot do, rather
than stating what they must do or how they will do it.
A brief example before turning to abortion policy may be helpful. Pres-
ident George W. Bush’s education initiative, No Child Left Behind, demon-
strates how the three branches of government can each contribute differently
to public policy. Although the passage of No Child Left Behind (NCLB) is
primarily credited to President Bush, the law was an amendment, albeit a
significant amendment, to an already exiting law, the Elementary and Sec-
ondary Education Act. Thus, while the President initiated this proposal, it
was ultimately Congress who had responsibility for drafting the legislation,
a process that is characterized by compromise and revision. As such, Con-
gress substantially revised President Bush’s initial proposal, including pro-
visions regarding school choice and the funding authorization for the policy.
Ultimately, the bill that made it to George Bush’s desk for his signature was
not the same proposal that he had submitted for consideration, largely
because separation of powers guarantees that Congress will have its own
interests and these interests are often reflected in the drafting of legislation.
Further, Congress is more open to various outside interests than is the Pres-
ident because of the large size and structure of the branch. In the case of
NCLB, Congress simply had more voices with which to contend when con-
sidering President Bush’s proposal.
After being signed into law, the President can have a great deal of
influence over a bill’s implementation. Namely, the President appoints peo-
ple to positions of authority in the executive branch who share his views and
interests in public policy. In the case of NCLB, Bush had appointed Mar-
garet Spellings as Secretary of Education, head of the executive branch
department responsible for drafting the rules and regulations necessary for
states and schools to carry out NCLB. The Department of Education’s reg-
ulations for NCLB offer guidelines on topics that range from same-sex class-
rooms, limited English proficiency students, to assessment testing for disabled
students. These regulations provide more specific direction to states and
schools, directions that are in line with the President’s priorities, yet are also
consistent with the law as written by Congress.
The Many Faces of U.S. Abortion Policy (SHOUSE)
61
In most cases of public policy, not everyone will be pleased with the
outcome or the outputs of the policy, and NCLB is no exception. If politi-
cal actors such as interest groups have not successfully influenced Congress
or the executive branch regarding a public policy, they often turn to the
remaining branch of the national government, the judiciary, to exercise
influence. For instance, NCLB spawned numerous lawsuits regarding the
national government’s level of funding to the states, primarily in regard to
the assessment testing provisions of NCLB. Although none of these cases
have yet to be settled, the Supreme Court may ultimately decide whether or
not the implementation of NCLB has violated the law regarding funding.
Further, the Supreme Court has ruled on other topics related to NCLB, such
as with Zelman v. Simmons-Harris (2002), in which the Supreme Court
decided that tax vouchers being used at private, religious schools did not
violate the First Amendment’s Establishment Clause regarding the separa-
tion of church and state.
Both the issues of gay marriage and of No Child Left Behind provide
examples of the influence our government structure has on the politics and
policies that emerge from the American political system. Clearly, the struc-
tures of federalism and the separation of powers can have a tremendous
effect on the policies and the policy process within the United States. In
regard to abortion policy, the influence of these structures is particularly
pronounced. In fact, one cannot fully appreciate abortion policy in this
country without understanding how it has been influenced by the very struc-
ture of government. It would be inaccurate to say that this is the only
influence on abortion policy, given that both opponents and proponents of
abortion rights, both in and out of government, have influenced abortion
policy in this country. But the very tactics used by interest groups and gov-
ernment officials are fundamentally shaped by federalism and separation of
powers.
The remaining section of this essay will consider how the structure of
American government has influenced abortion policy and the politics
surrounding abortion policy. In addition to a discussion of the influence
that federalism and the separation of powers has had on abortion policy, this
section also includes references to the various resources one can use for
conducting research on government policy, including abortion policy.
INTERDISCIPLINARY VIEWS ON ABORTION
62
The Effect of Federalism on U.S. Abortion Policy
While Americans generally consider the source of abortion policy to be
the Supreme Court case Roe v. Wade (1973), it’s important to reiterate that
abortion policy is primarily under the jurisdiction of state governments.
What Roe v. Wade accomplished was to apply the implicit right to privacy,
found in the Bill of Rights and the Due Process Clause of the Fourteenth
Amendment, to a woman’s decision to end a pregnancy. In very practical
terms, the court simply overturned a Texas law that had banned abortion,
claiming that the law violated a woman’s right to privacy, which then pre-
vented other states and the federal government from making abortions ille-
gal up until the point of fetal viability. However, short of making it illegal,
states can do much to influence the actual practice of abortion. This relates
to James Madison’s point that regional variation can best be represented by
state governments rather than by a single national government. Although
we do see similarities across the states, with fifty states each making policies
regarding abortion, it’s impossible to identify one single abortion policy for
the nation.
Currently, there are numerous on-line resources for researching abor-
tion policy in the American states. These can range from organizations that
advocate for a particular stance on abortion, to non-partisan organizations
that provide objective current information about the practice and regulation
of abortion. For instance, for information with a “pro-life” perspective, the
organization National Right to Life provides a thorough website, as does
Operation Rescue, which is also a very active pro-life organization with reli-
gious ties. Conversely, those interested in information with a “pro-choice
slant can turn to the National Abortion Rights Action League (NARAL) or
the National Abortion Federation, both of which provide thorough infor-
mation about abortion rights. There are many abortion websites that take a
particular political or ideological slant, although the reader must be careful
to evaluate the value of the information provided. Two excellent on-line
resources available at the time this volume was published that provide non-
partisan information about the abortion policies of each state are the
Guttmacher Institute and the Kaiser Family Foundation. These two organ-
izations monitor abortion policies, as well as other types of policies, to pro-
vide objective information about the practice of abortion in the United
States. All the organizational websites mentioned above are accessible to any-
The Many Faces of U.S. Abortion Policy (SHOUSE)
63
one who has access to the Internet. For readers with access to on-line sub-
scription databases through their library, Lexis Nexis State Capitol Universe
is also an excellent resource for researching state laws on any subject, includ-
ing abortion.
The websites devoted to abortion and abortion politics make clear the
importance many people place on this issue. Yet, attitudes toward abortion
vary widely across the United States, from the more liberal position protect-
ing the rights of women regarding their reproductive health, to the more con-
servative focus on a fetus’s right to its life. State public policies regarding
abortion mirror the public’s perspectives, ranging from states with more lib-
eral, permissive abortion policies to those with more conservative, restric-
tive policies (Cook, Jelen, & Wilcox, 1993). While all states regulate the
practice of abortion to some degree, the regulation can vary widely, from a
focus on the physicians who conduct abortions, to a focus on the girls and
women who seek an abortion. One interesting aspect of federalism is that a
state can “learn” from other states and essentially copy what its policymak-
ers consider to be a good idea from another state. Thus, while state policy
on abortion can vary from state to state, one can see considerable overlap in
the types of policies states adopt to regulate abortion.
The policies a state adopts in regard to abortion are related to the goals
that state’s policymakers are attempting to promote. These goals can be
largely routine and non-controversial, such as promoting the general pub-
lic health, or they can be paternalistic and obstructionist, making abortion
a less attractive, and even downright difficult, option. Policies related to
abortion, however, all tend to relate to the concept of protection. States
make policies to protect individuals from harm and to protect society as a
whole. Of course, opinions on what and whom need protecting vary from
person to person, and state to state. In regard to the more routine forms of
regulation, all states act to protect public health by regulating the medical
profession, including those within the profession who perform abortions.
States regulate and license many occupations, from physicians and insurance
agents to barbers and truck drivers, with the goal of securing public safety
and well-being. In regard to abortion policy, these policies are directed at
the people who perform abortions, rather than at the women who are seek-
ing or having an abortion. For instance, thirty-nine states require that abor-
tions be performed by a licensed physician. As such, anyone performing an
abortion in one of these states who is not a licensed physician can be pros-
INTERDISCIPLINARY VIEWS ON ABORTION
64
ecuted. Further, a large minority of states require that abortions be per-
formed in a hospital. In nineteen states, it is illegal for a physician to per-
form an abortion in her or his office, even though physicians in other states
may be free to do so. This is an example of how federalism creates a virtual
“patchwork quilt” of policies across the country. What is legal in one state
may be illegal just over the state line.
A second goal of abortion policy is to protect the interests of “others,”
whose rights may be harmed by a woman’s decision to have an abortion. For
example, most states, currently thirty-five, require some sort of parental
involvement if their minor daughter is seeking an abortion. Specifically,
twenty-two states require that a parent gives his or her consent before an
abortion can be performed, while eleven states simply require that one or
both parents be notified. The laws of two states require that both parental
notification and consent be obtained. Fifteen states either do not have such
a provision in their statutes, or court orders have prevented them from being
carried out. In the thirty-five states with this requirement, it is clear that the
rights of parents to be involved in their child’s healthcare decisions is pro-
moted, even if that makes obtaining an abortion more difficult for the young
woman. In cases where parental notification is impossible or inadvisable,
most states with parental notification policies allow for some sort of court
approval for the abortion, although this is a lengthy process. A few states
allow a physician to waive the parental notification or court approval in cer-
tain circumstances, but this is rare.
Taxpayers are another group of people states attempt to “protect” by
prohibiting the use of public funds for abortions. In 1977, Congress passed
the Hyde Amendment, named for Representative Henry Hyde (Rep- IL),
which prohibited abortions from being covered by Medicaid funds except
when the life of a woman was endangered.3This restriction on Medicaid-
funded abortions was loosened in 1993 when exceptions to the prohibition
on funding were extended to cases of rape and incest. Because Medicaid is
a program funded both by the federal government and the states, states have
some latitude as to how the funds will be used in regard to paying for abor-
tions. Consequently, there is some variation as to how rigorously the Hyde
Amendment is implemented. Most states, a total of thirty-two, largely fol-
low the federal government’s lead of only funding abortions when the preg-
nancy endangers the woman’s life, or is the result of rape or incest. Seven of
these thirty two states have extended the exceptions slightly, including cov-
The Many Faces of U.S. Abortion Policy (SHOUSE)
65
erage of an abortion when there is an abnormal fetus or when the pregnancy
would cause long-term harm to a woman’s physical health. Seventeen states,
however, fund all or most “medically necessary” abortions, a term that gen-
erally means any abortion that is performed by a medical professional who
is licensed by the state to perform abortions. South Dakota will only fund
abortions if a woman’s life is in danger, in violation of the Hyde Amend-
ment. A policy to fund medically necessary abortions offers low-income
women much fewer restrictions for obtaining an abortion than a policy that
follows the Hyde Amendment provisions.
A third goal of abortion policy is to protect the fetus from what the
state considers to be unreasonable harm. States can set parameters as to when
during a pregnancy an abortion can be performed. Although fourteen states
have no restriction on when abortions can take place during a pregnancy,
thirty six do prohibit abortions in the latter stages of a pregnancy, unless the
woman’s life is at risk. This prohibition varies, ranging from fetal viability
in twenty-three states, to the third trimester of pregnancy in five states, to
the twentieth or twenty-fourth week of pregnancy in eight states. In half of
the states prohibiting abortions after a certain point in the pregnancy, a sec-
ond physician must be consulted before an abortion can take place if it is
deemed that a woman’s life is at risk. Several states have also prohibited a
particular abortion procedure. Although rare, thirteen states have prohib-
ited the “intact dilation and extraction” method of abortion, which is often
referred to as “partial birth abortion” by opponents to abortion rights. The
constitutionality of these laws have been questioned in several states, but the
Supreme Court ruled in 2007 (Carhart v. Gonzales) that a federal prohibi-
tion on the procedure, the Partial Birth Abortion Ban of 2003, is permissi-
ble under its interpretation of the Constitution. This ruling may usher in
greater adoption of this policy in other states.
A final goal served by abortion policies is to ostensibly protect the emo-
tional well-being of a woman who is considering an abortion. While a
woman’s health is protected by the state’s regulation of abortion providers,
the state addresses a woman’s emotional health by aiming policies toward
the woman herself. These policies are often designed to delay the process of
obtaining an abortion, to provide certain information about abortion, and
to even deter a woman from having an abortion at all. Many states mandate
that a woman seeking an abortion be counseled on the effects of abortion.
The most common types of counseling, required by twenty-six states, relates
INTERDISCIPLINARY VIEWS ON ABORTION
66
to alternatives to abortion and the types of services available if the woman
chooses to continue her pregnancy. Much less common is the requirement
by three states that women be counseled on the emotional effects of an abor-
tion, the requirement by four states that they receive information regarding
the pain felt by the fetus during an abortion, and the requirement by three
states that women be counseled on the incidence of breast cancer after an
abortion.
Most recently, Georgia has passed legislation, the “Woman’s Ultrasound
Right to Know Act,” which requires that physicians offer all women seek-
ing abortion the opportunity to view the ultrasound image and hear the fetal
heartbeat before an abortion takes place. A woman is not required to view
the image or hear the heartbeat, but the physician is required to ask. Accord-
ing the findings in the Georgia’s law (H.B. 147), the law will ensure that a
woman receive complete information on the “reality and status” of her preg-
nancy, that the fetus is protected from an uninformed decision, and that a
woman is protected from the “devastating psychological consequences” of
making an uninformed decision regarding abortion (Georgia H.B. 147). The
overt intent of this policy is to deter women from having an abortion, on
the assumption that hearing a heartbeat and seeing an image makes the fetus
more human and “real” to the pregnant woman. Other states that have sim-
ilar laws are Mississippi, Alabama, Michigan, and Arkansas. In March of
2007, the South Carolina House of Representatives attempted to take the
policy a step further by requiring that women view an ultrasound image and
hear the heartbeat of the fetus. Currently, the bill has not passed the state
senate.
The above discussion gives an overview of the most commonly used state
policies regarding abortion, although there are numerous variations from
state to state when looking at the details of each law. As can be seen by these
policies, the practice of abortion can be influenced dramatically by policy
makers’ goals and the policies they adopt to achieve their goals. It’s also
important to note that the goals they claim to promote may actually be
designed to achieve other goals. For instance, is abortion defined merely as
a healthcare procedure? If so, then the state’s only interest is in making sure
it’s carried out by trained professionals in a safe environment. But defining
abortion in this manner ultimately promotes abortion rights, even if that may
not be the stated goals of policymakers. Further, is abortion a decision that
affects only the woman who obtains the abortion? If not, whose rights take
The Many Faces of U.S. Abortion Policy (SHOUSE)
67
precedence over the woman’s: parents, the fetus, society? (See the essay in
this volume by Martinelli-Fernandez). By clarifying in policy that others
may have a legitimate interest in the practice of abortion, the state effec-
tively establishes barriers to women who seek an abortion. These barriers can
be costly, in both time and money, for the woman seeking an abortion. For
the healthcare professionals who provide abortion service, these barriers may
be costly enough that they choose to no longer offer the service. In essence,
the more the state requires of people who perform abortions, the more
difficult it is to offer the service. Thus, abortion may be legal, but largely
unavailable, in some states because of the policies that state has adopted
regarding the procedure (See Rose, 2007).
Although this section has focused almost exclusively on the variation
of state abortion policies allowed by a federalist system of government, it’s
important to note that federalism also includes consideration of the national
government’s role in policy making. While the national government is
involved in abortion policy, there isn’t just one source of policy within the
national government. In fact, there are three sources of policy, found in the
legislative, executive, and judicial branches of the national government, and
these three branches do not always speak with a single voice or intent on
policy issues. As with federalism, separation of powers makes it difficult to
speak of a single national abortion policy. Rather, there are numerous poli-
cies related to abortion that have emerged from the national government.
The next section addresses the effect the separation of powers has had on
abortion policy in the United States.
The Effect of Separation of Powers on Abortion Policy
As already discussed, the United States’ national government is charac-
terized by a division of power which gives each branch its own powers and
responsibilities. These powers overlap with those of the other branches how-
ever, which theoretically contributes to each branch being able to check the
excesses of either of the other two. Not only does each branch have its own
powers, but it is also differentiated from the other branches in terms of its
members’ method of appointment, their term of office, and the scope of
their representative function. The founders of the Constitution reasoned that
the members of each branch would have different interests than the mem-
INTERDISCIPLINARY VIEWS ON ABORTION
68
bers of the other branches because they would have to act differently to
remain in office. For instance, a member of the House of Representatives
must go up for reelection every two years and she represents a district of
almost 700,000 people. Clearly, she would have to act differently to appeal
to her constituents than would a U.S. Senator, who only faces reelection
every six years and represents an entire state’s population. Both the House
member and the Senator would behave differently than the President, who
faces reelection every four years, can be elected no more than two times, and
represents the entire country. Even more unique, members of the federal
judiciary have different incentives built into their office; they are appointed
by the president, confirmed by the Senate, and serve life terms. Thus, the-
oretically, even if the same political party controls all three branches of gov-
ernment, the three branches will not always see eye to eye, simply because
the incentive structures built into each branch differ.
Contributing to this effect is the fact that none of the branches are
static; they change, depending on who is elected and which party is in power
of each branch. Clearly the presidency of Bill Clinton was different from the
presidencies of both George H. W. Bush and George W. Bush, his prede-
cessor and successor. Similarly, as the party in control of Congress shifts
from Republican to Democrat, so does its relationship with the other two
branches of government. Given that the government changes over time, the
policies that emerge from that government can also change over time. Thus,
national abortion policy varies, depending on which branch is making the
policy and the political circumstance of the time. This section will look at
each branch in turn, discussing the various types of abortion policy that each
has approved.
Among the three branches of the national government, the Supreme
Court has played the most visible role in the national government’s policy
towards abortion. The Supreme Court has several powers at its disposal,
including the interpretation and application of law when cases arise, the
interpretation and application of the Constitution to state and national poli-
cies when the Constitution and the policy seem to be at odds, and the dis-
cretion to hear or not hear cases that are appealed to it. Court decisions
generally outline what is permissible or impermissible within the confines
of a statute or the Constitution’s language. Rarely does a court decision say
what must be done, but rather clarifies what can or cant be done. Unlike
the Congress and the President, the checks on the court’s powers are some-
The Many Faces of U.S. Abortion Policy (SHOUSE)
69
what indirect. Probably the two most potent checks on its power include
the reactive nature of its policy making, in that it can only make policy when
a case is brought before it, and its inability to carry out its own decisions.
In short, the court has to depend on others to implement its decisions, an
act which becomes less assured if the decisions of the court are perceived to
be illegitimate by the public that is affected by the decision or other parts
of government.
The Supreme Court made one of its first forays into the issue of repro-
ductive rights in 1965, when deciding the case Griswold v. Connecticut. In
this case, physicians at a Connecticut Planned Parenthood clinic were pros-
ecuted for giving information about contraception and selling contraceptive
devises to married couples, which was in violation of Connecticut law at the
time. In addition to the portions of the law directed at healthcare providers,
the law also targeted the individuals who would use contraception. The
appellants, who had been found guilty and fined in lower court, argued that
the Connecticut law violated the Due Process Clause of the Fourteenth
Amendment to the Constitution. The Supreme Court ultimately reversed
the decision of the lower court, claiming in its opinion that the Connecti-
cut law violated the Constitution’s right to privacy, a right not explicitly
mentioned in the Constitution but largely considered to be within the param-
eters of the other rights it provides. Because of the Court’s broad reading of
the Constitution, this state law was ruled unconstitutional and could no
longer be used to limit access to or information about contraception. The
application of the constitutional right to privacy to reproductive rights laid
the groundwork for Roe v. Wade in 1973.
One of the most controversial cases decided by the Supreme Court, Roe
v. Wade overturned state laws that prohibited abortion, using a similar ration-
ale as offered in Griswold v. Connecticut, that the reach of government does
not extend to a woman’s right to make her own reproductive choices. As
seen in the discussion of federalism, the decision still gave the states some
discretion in regulating the practice of abortion, but the Court’s opinion flatly
stated that laws outlawing abortion prior to fetal viability were unconstitu-
tional and thus, invalid. While the foundation of abortion legality estab-
lished by Roe v. Wade remains intact, many have argued that the court has
chipped away at abortion rights by allowing states to increasingly impose
limitations on the practice of abortion, as seen in the discussion of state
abortion policies above.
INTERDISCIPLINARY VIEWS ON ABORTION
70
Why has this change in court decisions taken place? In short, the answer
comes down to changes in the ideologies and views of the people who serve
on the federal courts. With nine justices on the Supreme Court, currently
appointed by four different presidents, it’s not surprising that they do not
share a single interpretation of law or the Constitution. As the people on the
court have changed over time, as presidents appoint new justices who reflect
their own political views, the interpretation and application of constitutional
provisions often change. This has clearly influenced the judicial decisions
being made in regard to abortion policy. While Roe v. Wade was a clear
advancement of the national government’s role in making abortion policy,
the trend since this case has been to give the states more discretion in how
they regulate abortion, short of making it illegal. However, even at its zenith,
judicial abortion policy tends to be broad, making decisions as to what states
can and cannot do regarding abortion regulation, not necessarily what they
must do regarding abortion. That level of specificity from the national gov-
ernment comes from policies made by Congress and Executive branch.
As the elected representative body within the national government,
Congress ideally translates public opinion and interest into legislation. While
laws can be written in broad language, the scope of legislative abortion pol-
icy tends to be significantly narrower than the policies made by federal judi-
ciary. For instance, while Roe v. Wade broadly prohibits states from infringing
upon a woman’s right to privacy by making abortion illegal, Congress focuses
on more discreet topics, such as whether the national government will fund
abortions. However, like the courts, Congress is not immune to the effects
of changing political party leadership, and since 1994, the party leadership
of Congress has changed twice. Consequently, the focus of federal law regard-
ing abortion has varied over time.
Currently, the database Lexis Nexis Congressional makes it relatively sim-
ple to see the various laws Congress has passed that include any considera-
tion of abortion. Notably, since Roe v. Wade Congress has passed only
twenty-nine laws that include any provisions regarding abortion. In fact,
twenty-one of the twenty-nine simply include abortion as one item in a
more comprehensive law that appropriates funds for some function of the
government. For instance, in several of the laws appropriating funds for the
Department of Defense, Congress has clarified that none of the appropria-
tion could be used for purposes of abortion. Given the amount of talk devoted
to abortion by candidates for congressional office, it is perhaps surprising
The Many Faces of U.S. Abortion Policy (SHOUSE)
71
that this is by far the most common approach to abortion policy by Con-
gress. Looking at the twenty-nine laws passed since 1973, this prohibition
against using federal funds for abortion services is as close as Congress gets
to any kind of theme in abortion policy. The remaining eight laws that con-
sider abortion address a variety of topics. These range between restrictions
on certain types of abortions, such as the federal ban on late term abortions
in the Partial Birth Abortion Ban of 2003, to the protection of women who
are trying to access abortion clinics in the Freedom of Access to Clinic
Entrances Act of 1994. The three most recent of these laws have implica-
tions for abortion rights, even if the subject of the law is not abortion, per
se. In addition to the Partial Birth Abortion Ban of 2003, these include the
Born-Alive Infants Protection Act of 2002, which clarifies that a baby who
is born alive, after a failed abortion for instance, is considered a person under
federal law, and the Fetus Farming Prohibition Act of 2006, which prevents
the use of aborted fetuses for medical research. Beyond these three, there
does not appear to be a common theme or approach to abortion in the
remaining non-appropriations laws.
Generally, members of Congress pass laws when problems come to their
attention and there is enough political support for the policy to pass. Thus,
because new problems emerge over time, or our perceptions of problems
change, it is difficult to see a consistent or coherent train of congressional
policy regarding abortion, other than the prohibition on its funding. The
difficulty in passing a coherent, consistent policy is exacerbated by several
factors. First, Congress is a large institution which is divided between the
House of Representatives and Senate, and for any law to pass, it must receive
majority approval in each of the chambers. In fact, no bill can be sent to
the President that has not been approved by both the House and the Sen-
ate, a difficult and time-consuming process in even the best of circumstance.
But on a contentious issue like abortion, it can be extremely difficult to
secure a majority vote, even when bills are drafted in such a way as to min-
imize conflict. A second difficulty in passing coherent policy over time is the
role of political parties in providing leadership to each congressional cham-
ber. If the political party in control of a chamber changes, not only may that
chamber adjust its proposed solutions to problems, but the very conceptu-
alization of what is a problem can change. Thus, abortion policy across time
is influenced by the public’s perceptions of abortion, who that public elects
to Congress, what party controls the chambers of Congress, and what mem-
INTERDISCIPLINARY VIEWS ON ABORTION
72
bers of Congress are willing to do about an issue fraught with conflict. In
short, the approach Congress has taken has been to refuse to pay for abor-
tion with federal funds, a decision that is largely supported by the public,
and to simply deal with individual issues related to abortion as they arise.
The last branch of the national government to be considered is the exec-
utive branch, and it too has its own influence over abortion policy. With
one exception, the President’s influence on abortion policy is more indirect
than that of the other two branches of the national government. As the head
of the executive branch, the President has the power to nominate all federal
judges and justices as well as the leadership positions of the executive branch.
Thus, when the President has the opportunity to fill a vacancy on the
Supreme Court, the President can appoint people who share his or her views
on numerous issues. Abortion has been one of the issues past presidents have
considered when they have nominated people to the federal judiciary. While
the President has to be conscious of attitudes in the Senate when he or she
appoints someone to the courts, given that the Senate must confirm these
nominations, a president still has a great deal of discretion in choosing some-
one who shares his or her political views on the role of the government in
regard to the practice of abortion. The same discretion is granted to the Pres-
ident’s power of appointment to officials in the bureaucracy, although the
bureaucracy’s influence over abortion policy is somewhat muted.
The President also has the power to veto legislation that comes to his
or her desk from the Congress. This power has been used on two major
occasions on abortion bills: during the administration of President Clinton,
the Republican-controlled Congress passed the Partial Birth Abortion Ban
twice, only to have it vetoed both times by the President. Both vetoed bills
prohibited late term abortions unless the life of the woman was at risk, while
President Clinton explained in his veto message that he would not sign the
legislation unless there was an exception if a woman’s health was also endan-
gered. Congress was not able to get the law passed until the political envi-
ronment had changed with the election of Republican President George W.
Bush. Although Congress can override a presidential veto with a two-thirds
vote, this overwhelming majority is extremely difficult to achieve and, as
such, overriding a veto is very rare.
The most direct influence the president has on abortion policy is
through the use of executive orders, which is the President’s ability to direct
the executive branch in matters not specifically addressed in law. During his
The Many Faces of U.S. Abortion Policy (SHOUSE)
73
administration, President Ronald Reagan issued an executive order that pre-
vented any foreign aid for family planning to be distributed to clinics or gov-
ernments that perform or counsel regarding abortion. Clinics worldwide
could continue to discuss abortion as an option with clients, but they would
relinquish necessary American aid if they did so. Although Congress had not
considered this particular issue in law, the President does have the discre-
tion to direct the executive branch as to how it must operate, as long as these
directives do not violate law. In this case, Congress had appropriated funds
for assistance to family planning clinics worldwide, but these appropriations
had further limitations imposed on their distribution by the President. After
President Reagan, this executive order was retained by President George H.
W. Bush, but was promptly overturned by President Clinton when he took
over the office. George W. Bush reinstated the order when he became Pres-
ident. Not only does the shift in policy affect the United States, but it has
clear implications for reproductive policies worldwide.
By looking at each of the three branches of the national government,
one can see that there is little coherent thread of public policy at the national
level regarding abortion, except perhaps in regards to the prohibition of its
funding. Given the federalist nature of our government, this is understand-
able. Abortion policy is largely the domain of the state governments. In the
states, we do see a policy trend toward protectionism, although the subject
of state protection (healthcare providers, the unborn, taxpayers, and women)
varies across policies. However, the national government is limited, consti-
tutionally, to certain types of action. How national funds can or must be
spent, or not spent in this case, certainly falls within the discretion of Con-
gress and the President. Beyond the issue of funding, however, abortion pol-
icy at the national level has been somewhat disjointed, made as issues emerge
out of the current political environment. Separation of powers provides each
of the three branches its own powers and motivations and its own mecha-
nism for effecting policy. This governmental structure has clearly influenced
the types of abortion policies coming from the national government.
Conclusion
The politics of abortion policy is complex and cannot fully be under-
stood without addressing the roles played by political parties, interest groups,
INTERDISCIPLINARY VIEWS ON ABORTION
74
candidates, and elections in the creation of abortion policy. This essay has
attempted to demonstrate that all other facets of abortion politics in the
United States are shaped, at their foundation, by the very structure of the
American government. Because the United States is geographically large and
diverse, it would be impossible to identify a single “public opinion” in regard
to abortion, since views vary so widely. These various views are reflected by
our parties, by the political interest groups that work to influence abortion
policy, and the candidates who run for office. But it is the structure of fed-
eralism and the separation of powers that allow that diversity of opinion to
find purchase in public policy across the United States, expressed through
the various laws and policies across all levels of the American government.
Notes
1. The Tenth Amendment to the Constitution states that the “powers not delegated
to the United States by the Constitution, nor prohibited by it to the States, are reserved
to the States respectively, or to the people.”
2. In The Federalist Papers, Number 51, James Madison advocates “contriving the inte-
rior structure of the government as that its several constituent parts may, by their mutual
relations, be the means of keeping each other in their proper places” (Madison 1961: 320).
It’s fascinating that the very structure of government was designed to keep each branch
in its proper place. Madison believed that giving each branch of government its own pow-
ers would motivate those officials within each branch to jealously guard their powers
from encroachment by the other branches. In fact, he assumed that it was the very desire
to usurp the powers of the other branches that would ultimately keep each branch in its
place. In Federalist 51, Madison famously articulates this assumption of political moti-
vation for power by saying that “ambition must be made to counteract ambition” (Madi-
son 1961: 322).
3. Medicaid is a health insurance program, created by the national government and
administered jointly with the states, to provide health care services primarily to low
income people.
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Hidden in Plain View
An Overview of Abortion in