CHAPTER FIFTEEN
MAGIC BULLETS

In the search for escape hatches, three major paths have been suggested. One changes abortion technique in a way that proponents hope will be more workable, one allows more people to legally become abortion providers, and the third gets more doctors by mandating abortion training for medical students. These methods are not likely to have the hoped-for impact.

DRUG-INDUCED ABORTIONS

The former head of the Food and Drug Administration, David Kessler, referred to RU-486 not as a pill, but as a regimen. This is a far more accurate way of looking at it. Unfortunately, much of the political debate acts as if a pill is all it is.

After going through the appropriate blood tests, pelvic exams and sonogram, the woman takes the pill and goes home. She returns in two days for a shot of prostaglandin. The side effects to this are awful, but the failure rate drops from 15 percent to three percent that way. In a week, if this chemical miscarriage is not complete, then a surgical abortion is done. Actually, it's not always done. Babies have been born after mothers whose RU-486 didn't work changed their minds. But the idea is that a surgical abortion is done if the drug regimen fails.

This involves at least three visits to the clinic -- one for the initial tests and pill, one for more tests and the injection, and a final one to see that it's complete, and do the surgical abortions if it's not. In France, a fourth visit for more monitoring is expected. It takes about a week to do it all.

Anyone who has been through a miscarriage, either the woman herself or any men that are around at the time, know that a natural, unavoidable miscarriage is traumatic. Sitting around the house waiting for one, knowing that it's about to happen, is heavy anxiety. The very president of the original company to manufacture the drug calls it "an appalling psychological ordeal." [1]

The New York Times reported in an article entitled "Surprising Journey for Abortion Drug," on March 23, 1994 on Americans who had travelled to England for the regimen at the Marie Stopes Health Clinic. One said, "It hurt so much, I felt like I was dying." Another said, "I was surprised by how much it hurts."

A week long period of initiating an abortion and waiting for it to happen is being pushed by people who would otherwise throw a fit over a 24-hour waiting period between receiving information and starting the abortion.

Using two drugs can be expected to have an impact over the whole body. One of those two, prostaglandin, is already known to have negative side-effects. This is well documented in a book written by strong abortion defenders at MIT [2]. Ms. Magazine has run articles pro and con. Because of the issue of women's health concerns, not all abortion defenders are full of boundless enthusiasm for this new method.

More recently, another regimen has been developed using drugs that are already widely available for other uses. After similar lab work, a shot of methotrexate is given. About a week later, a vaginal suppository of misoprostal is given in order to induce the uterine contractions that will expel the embryo, probably several hours later in the privacy of the woman's own home. Another week later, a sonogram must be done to see that it worked. If not, another dose of misoprostal or a suction procedure is done. This whole process requires at least two weeks of attention.

Those who do have enthusiasm see the drugs as a possible magic bullet to solve the biggest problem they have -- the availability of those willing to do abortions.

If picketers were the problem, this regimen would worsen the situation. Having the woman take three or four visits to that clinic, going through all the picketers more than once, would surely not be an improvement. If the picketers were the only reason doctors were leaving the field, abortion defenders would have to come up with a far better solution.

If the stress of seeing the violence directly is, in fact, the problem with keeping doctors willing to do abortions, then that defense strategy is obviously necessary. If a doctor is able to inject the customer and send her home to expel the baby, obviously the women will have the see the results, but the doctor won't.

But distancing is -- by definition -- being out of touch with reality. People will ultimately discover that the belief that they can psychologically insulate themselves from the violence is nothing more than a self-inflicted illusion. Victims may sometimes have the ability to protect themselves, but in the final analysis, perpetrators never do.

NEW ERA

The reason stated as to why we most desperately need this new method is the idea that it will change the face of the abortion debate. As Pamela Maraldo, then president of Planned Parenthood Federation of America, put it, "This will mark the beginning of a new era. It will go a long way toward ending the abortion wars." In other words, it's seen as a magic bullet to end the current raging conflict.

Columnist Ellen Goodman explains why this would be. "RU-486 is used in the earliest weeks of pregnancy. At four weeks, there are not 'silent screams' and no images to blow up into poster fetuses. Public support for a woman's right to decide is greatest at this stage . . . More importantly, you don't need a clinic to take a pill. In the past couple of years, the pro-life movement has shifted its tactics from winning cases to closing clinics, from passing laws to harassing patients. But with RU-486, abortion will no longer have to be limited to clinics, hospitals, and the handful of doctors easily targeted as 'the weak link' of abortion. The pill can be offered by trained physicians in a thousand offices. As Maraldo says, 'This will quiet and privatize the debate. It will take the debate off the streets and away from the clinics and bring it back to the minds of American women where it belongs.' The pill will never entirely replace surgical abortions. Nor will it change the moral and emotional dimensions of the decision faced by a woman with an unwanted pregnancy. But it will make her choice easier to exercise."[3]

The "silent screams" bother Ms. Goodman enough to desire a lack of them, and she perceives the distancing strategy as necessary to get more doctors involved. But the embryo does still have a beating heart and human features at this point. The woman who is no longer shielded from this, who sees the little human body after it comes out, is not likely to be comforted by the fact that that embryo was too small to be seen with current sonograph technology.

RU-486 won't entirely replace surgical abortions? In England, where this regimen is already available, it's chosen by only eight percent of women at this point. As an editorial in the St. Louis Post Dispatch put it: "Two years after the abortion pill's introduction into Great Britain, two major abortion centers report eight to ten RU-486 procedures weekly compared to between 500 and 600 surgical abortions. According to Family Planning World, reasons for the abortion pill's unpopularity include the fact that it takes more time and more visits, costs considerably more, requires a longer stay, produces more bleeding, uses hospital space and more staff time and is a long drawn-out process."[4]

The biggest problem, though, is the startling concept that the technique will mean a move away from the clinic. It's true that decentralizing the provision of abortion is absolutely essential, because having abortion available primarily in a few centers makes it remarkably vulnerable. The trend of centralization has created weak links. A strategy to spread it out is a prudent strategy.

However, this regimen involves at least three trips to the medical facility, and on one of those trips, the woman must stay for hours to be monitored on the side-effects of the prostaglandin shot. The methotrexate regimen similarly involved at least three trips and a lot of monitoring. Occasionally, a woman who sees the embryo coming out at home is going to freak out and let the staff know about it. That would go far to doing in the distancing routine. The members of the Board, other doctors, and other patients still won't stand for it. The label of abortionist will still apply. The trend toward assembly-line provision might over-ride safety concerns.

There is nothing about this technique that would make it spread out much beyond the clinics that already do abortions. All in all, this method doesn't quite look like the magic bullet solution that abortion defenders are desperately searching for.

DO WE NEED TO HAVE ONLY DOCTORS DOING ABORTIONS?

One of the few restrictions on abortion that was still allowed by Roe v. Wade in 1973 was that the state could require only licensed physicians to do them. This was hailed as a major advance over the back-alley butcher period. Yet now there are people seriously suggesting that one way to ease the shortage of abortionists is to allow people with less medical training than doctors to do them.

In fact, even the American College of Obstetricians and Gynecologists is recommending that non-physicians be trained to perform abortions. This major policy shift is tied to the dwindling supply of abortion providers.[5]

Abortion providers themselves, however, tend to oppose this suggestion. According to the Project Choice survey, although almost 80 percent perceive that there is in fact a shortage, almost 79 percent do not feel that non-physicians should be allowed to do abortions. About 76 percent of those who said that there is in fact a shortage nevertheless said that the field should not be opened up to people who are not physicians.

Since early abortions are less complicated, it would seem logical that a higher percentage of "early-term" providers would approve of non-physicians being allowed to do abortions than "late-term" providers. But those who only perform first trimesters opposed allowing non-physicians to perform them by almost 84 percent. They opposed it by a higher margin than the respondents as a whole.

It isn't odd that it would occur to abortion defenders to use non-doctors, however, because in fact that's already been done in the legal period, even if it is illegal. The results, however, are not encouraging. For example, the 60 Minutes piece on Hillview, an abortion clinic in Maryland, reported that Barbara Lofton had presented herself as a doctor, was not one, and had done abortions. The whole point of the report was how women had been injured at that clinic.

No one is proposing that abortions be done by people without medical training at all. The proposals are for nurse practitioners and/or midwives to be able to take on the duty, with doctors as backup in case of complications. Yet the system is already lacking in sufficient accountability and license supervision. The proposals are to loosen up something that is already too loose.

Those proposing this have not looked at the reasons that the pool of practitioners is dwindling so much, and are not even thinking of addressing the root causes. The dynamics of abortion with medically-trained non-doctors is not going to be that much different from the current situation. The stress is exactly the same, and lack of appreciation isn't likely to be better. The stigma may well be worse. They don't have the aura of prestige a physician would normally get just for being an M.D. They may have the back-alley image to shake.

But one of the biggest flaws in this proposal is the assumption that if we add more people to the pool of those legally qualified to do abortions, we will in fact have more people willing to do them. Are all the doctors doing them now going to stay in the field? Are they going to stay when, after all the guff they've had to put up with, they're being told that the work they do can just as well be done by people with less medical training?

The de-medicalizing of abortion that has already occurred has done wonders for short-term business, but has been disastrous for the industry in long-term consequence. The fight against informed consent legislation is a prime example, and the counselors who get paid for every abortion they sell is another. This has increased a sense of moving away from professionalism.

It has also made it seem to some women to be more like a commodity rather than medical care. Women treating the procedure like a commodity is one of the things doctors are finding frustrating. Thus, bringing in non-physicians may actually increase the dynamic that is discouraging physicians from keeping at it, without really bringing in enough people to make up for it.

The nurse practitioners that are being proposed as alternative abortion providers are primarily women, while current abortion providers are primarily men. The idea that work that men are becoming unwilling to do should be sloughed off on women is causing discomfort to many. But the question of whether this is workable also needs to be asked.

About one-fourth of ob/gyn doctors are female. No one has figures for what percentage of abortion doctors are female, but various samplings show that the portion is well less than that. Furthermore, the academic literature has already identified the problem that nurses are more likely to be upset by abortion work than doctors are.[6] Nurses are closer to the fetus and more inclined to identify with it, but this has been said by researchers who were clearly favoring abortion availability themselves. The idea wouldn't occur to them that maybe the nurses, being women, were more inclined to identify with the pregnant woman, and thus identify with her in a way that shared her sense of disturbance over going through a traumatic event.

Part of the theory of letting nurse practitioners, primarily women, do abortion is that, as women, they will be more inclined to identify with the woman and give her more tender care. Dr. Suzanne Poppema, an abortion doctor, herself had a second-trimester abortion [7]. Enough women have had abortions that large numbers of them are in the medical field.

Still, the fact remains that women doctors who are already professionally qualified to do abortions are not joining the field in droves. They are under-represented among abortion providers now.

One valid explanation for this is the suggestion that identifying with the aborting woman actually means sharing more pain than women practitioners wish to bear.

Nurse Sallie Tisdale comments, "I watch a woman's swollen abdomen sink to softness in a few stuttering moments and my own belly flip-flops with sorrow." [8]

The article in the American Medical News gives another example.

A nurse who had worked in an abortion clinic for less than a year said her most troubling moments came not in the procedure room but afterwards. Many times, she said, women who had just had abortions would lie in the recovery room and cry, "I've just killed my baby. I've just killed my baby. "I don't know what to say to these women," the nurse told the group. "Part of me thinks, 'Maybe they're right'. Such self-doubt is not uncommon to the abortion field."[9]

In both these cases, it is not identifying with the fetus, but identifying with the woman that causes these abortion workers distress.

It appears that the pool of people that's being looked at for extra abortion providers may not really be that eager. In addition, all the forces causing doctors to quit would still be strong.

Allowing non-doctors in may postpone the inevitable by making more providers available, but doesn't address the root causes of why people leave the field. Most ironic of all, it may not even succeed in making more providers available, because it will be a move that strongly discourages doctors from abortion practice.

MAKING THE DOCTORS DO IT

The Accreditation Council for Graduate Medical Education (ACGME) is made up of representatives from five groups, including the American Medical Association and the American Hospital Association. It voted unanimously on February 14, 1995 for a policy change to mandate abortion training for all medical students specializing in obstetrics and gynecology. Since the number of programs offering the training has been steadily declining and voluntary interest is at an all-time low and going lower, "choice" is not sufficient to keep doctors performing abortions. The next method is outright coercion.

All women and men who wish to specialize in obstetrics and gynecology are deprived of the right to choose to avoid participating in abortions. All women in the future would be denied the right to choose to have a doctor who has not participated in abortions. It is abortion that is important to the Council, not women's rights to make choices.

When mandating those doctors choosing a specialty in obstetrics, doctors most attracted to making a living delivering babies, they haven't selected those physicians most willing to comply with such a mandate.

An even more pragmatic problem arises with this mandate. Since the centralizing tendency has left most abortions performed in assembly-line clinics, those clinics are going to be the place where much training would need to take place. Training people would detract from the efficiency of the assembly-line. It would also obligate abortion doctors to have their own skills and practices on display before medical students, whose standards might be a bit different.

Ms. magazine noted this problem. "Residency programs are caught in a catch-22 that could render the new ruling meaningless: the vast majority of abortions are now performed in freestanding clinics at a much lower cost than in hospitals." Ms. quotes Terry Steyer of the American Medical Student Association as saying, "Those programs that do encourage residents to get abortion training use clinics such as Planned Parenthood, and these clinics are not equipped to handle the flow of residents that now have to be trained." Residency programs may have to be creative in finding ways to train, but they have little incentive because while technically programs that don't comply can lose their accreditation, John Gienapp, head of ACGME, says the council won't force any institution to require abortion training. Ms. Magazine concludes, "This hollow ruling leaves the pro-choice community fearful that the ranks of abortion providers will continue to dwindle."[10]

In fact, experience since this ruling has shown this to be the case.

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